Volume 21 • September 2015 • Number 3

Home , Cose della vita, Emotional flooding

ISSN 1592-1107

Official Journal of the Italian Society of Psychopathology Organo Ufficiale della Società Italiana di Psicopatologia

journal of psychopathology, 21 (3), 225-308, 2015 225-308, (3), 21 of journal psychopathology, Editor-in-chief: Alessandro Rossi

Editorial 225 Costituzione SOPSI GRUPPO GIOVANI e relativo Manifesto

Original articles 226 Early hyperprolactinaemia in acute psychiatric inpatients: a cross-sectional study 231 Parental alienation syndrome or alienating parental relational behaviour disorder: a critical overview 239 MISM: Clinical and epidemiological data of a new Italian Public Mental Health Care Model in development 246 Metabolic syndrome in acute psychiatric inpatients: clinical correlates 254 Exploratory factor analysis of the Mini instrument for the observer rating according to ICF of Activities and Participation in Psychological disorders (Mini-ICF-APP) in patients with severe mental illness 262 Can we modulate obsessive-compulsive networks with neuromodulation? 266 Treatment of resistant mood and schizoaffective disorders with electroconvulsive therapy: a case series of 264 patients 269 Strategies to implement physical health monitoring in people affected by severe mental illness: a literature review and introduction to the Italian adaptation of the Positive Cardiometabolic Health Algorithm

Assessment and instruments in 281 Validation of the Italian Version of the Aberrant Salience Inventory (ASI): a New Measure of psychopathology Psychosis Proneness 287 Italian version of the “Specific Level of Functioning” 297 Autism Rating Scale (ARS) – Italian version

www.gipsicopatol.it Volume 21 • September 2015 • Number 3

Founders: Giovanni B. Cassano, Paolo Pancheri

Periodico trimestrale POSTE ITALIANE SPA - Spedizione in Abbonamento Postale - D.L. 353/2003 conv.in L.27/02/2004 n°46 art.1, comma 1, DCB PISA - Aut. Trib. di Pisa n. 9 del 03/06/95 L.27/02/2004 n°46 art.1, comma 1, DCB PISA - Aut. Trib. - Spedizione in Abbonamento Postale D.L. 353/2003 conv.in SPA Periodico trimestrale POSTE ITALIANE Cited in: EMBASE - Excerpta Medica Database • Index Copernicus • PsycINFO • SCOPUS • Google Scholar Official Journal of the Italian Society of Psychopathology Organo Ufficiale della Società Italiana di Psicopatologia

Editor-in-chief: Alessandro Rossi

International Editorial Board D. Baldwin (UK), D. Bhugra (UK), J.M. Cyranowski (USA), V. De Luca (Canada), B. Dell’Osso (Milano), A. Fagiolini (Siena), N. Fineberg (UK), A. Fiorillo (Napoli), B. Forresi (Modena), T. Ketter (USA), G. Maina (Torino), V. Manicavasagar (Australia), P. Monteleone (Napoli), D. Mueller (Canada), S. Pallanti (Firenze), S. Paradiso (Iowa City), C. Pariante (Londra), J. Parnas (Denmark), S. Pini (Pisa), P. Rucci (Pisa), N. Sartorius (Switzerland), G. Stanghellini (Chieti), T. Suppes (USA), J. Treasure (Uk), A. Vita (Brescia) Advisory Board E. Aguglia, C. Altamura, A. Amati, L. Bellodi, M. Biondi, F. Bogetto, B. Carpiniello, M. Casacchia, G.B. Cassano, P. Castrogiovanni, F. Catapano, D. De Ronchi, L. Dell’Osso, M. Di Giannantonio, C. Faravelli, F. Ferro, F. Gabrielli, S. Galderisi, P. Girardi, D. La Barbera, C. Maggini, M. Maj, G. Muscettola, M. Nardini, G.C. Nivoli, L. Pavan, G.F. Placidi, R. Quartesan, A. Rossi, E. Sacchetti, P. Santonastaso, S. Scarone, A. Siracusano, E. Smeraldi, O. Todarello, E. Torre

Italian Society of Psychopathology Executive Council President: A.C. Altamura • Past President: F. Bogetto • Secretary: A. Rossi • Treasurer: A. Siracusano Councillors: E. Aguglia, A. Amati, M. Biondi, B. Carpiniello, M. Casacchia, P. Castrogiovanni, M. di Giannantonio, S. Galderisi, C. Maggini, G. Muscettola, G. Placidi, E. Sacchetti Honorary Councillors: G.B. Cassano, L. Ravizza

Editorial Coordinator: Roberto Brugnoli Managing Editor: Patrizia Alma Pacini Editorial Assistant: Patrick Moore Editing: Lucia Castelli, Pacini Editore Srl, Via Gherardesca 1, 56121 Pisa • Tel. 050 3130224 • Fax 050 3130300 • [email protected] • [email protected] Scientific Secretariat: Lucia Castelli, Pacini Editore Srl, Via Gherardesca 1, 56121 Pisa • Tel. 050 3130243 • Fax 050 3130300 • [email protected] • [email protected] © Copyright by Pacini Editore Srl Publisher: Pacini Editore Srl, Via Gherardesca 1, 56121 Pisa • www.pacinimedicina.it

www.gipsicopatol.it Volume 21 • September 2015 • Number 3

Founders: Giovanni B. Cassano, Paolo Pancheri Cited in: EMBASE - Excerpta Medica Database • Index Copernicus • PsycINFO • SCOPUS • Google Scholar Information for Authors including editorial standards for the preparation of manuscripts

The Journal of Psychopathology publishes contributions in the form of mono- support should be provided at the end of the paper, after the list of references. graphic articles, news, update articles in clinical psychopharmacology, forums Notes to the text, indicated by asterisks or similar symbols, should appear in the field of psychiatry. at the bottom of the relevant page. The material submitted should not have been previously published, and should not be under consideration (in whole or in part) elsewhere; it must conform Mathematical terms and formulae, abbreviations, and units of measure should with the regulations currently in force regarding research ethics. 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In the Conclusion(s) section should report the significance of the at least 300 dpi (100 x 150 mm). results as related to clinical implications. 3. Brief articles: this space is dedicated to brief communications of clini- The text must be written in English. The paper must include: cal and experimental data and to preliminary data of ongoing research of 1. Title (both in English and Italian); particular interest. The manuscript should not exceed 20.000 typewritten 2. Summary (in English) (Summary should be about 3000 typewritten characters, including the summary, tables, figures and references (max 10). characters (including spaces). It should be divided into 4 sections: Objec- tives, Methods, Results, Conclusions); 4. Case reports: brief articles (maximum 4000/4500 typewritten characters) 3. A set of key words (in English); in which clinical original experiences from medical practice are described. 4. Legends for tables and figures (each figure and/or each table on separate 5. Assessment and instruments in psychopathology. This section hosts articles pages, both in English and Italian); on psychological and psychopathological assessment instruments aiming at 5. Authors are invited to suggest 3 national or international referees improving knowledge of psychological functioning of those subjects with mental for their article. and behavior disorders in different reference models. The use of such instruments is not limited to clinical population but also includes non-clinical and general The first page of the manuscript must also contain the names of the Authors population. This section also accepts studies on validation and translation into and the Institute or organisation to which each Author is affiliated; the category Italian of instruments, new assessment instruments and competing studies of under which the Authors wish the work to be published (although the final decision rests with the Editor); the name, mailing address, and telephone new assessment instruments with other procedures of assessment than psycho- and fax numbers of the Author to whom correspondence and the galley pathological constructs. The manuscript should not exceed 40.000 typewritten proofs should be sent. characters, including the summary, tables, figures and references (max 35). 6. 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Annual subscription: identified in the text by Arabic numbers in upper script and listed at the end of € 70,00 for Italy; € 85,00 for all other countries; € 30,00 for single issues the manuscript in the order of mention. The first 3 Authors must be indicated, (when available). All correspondence concerning subscriptions (including followed by et al. Journals should be cited according to the abbreviations payments) should be addressed to: set out by Index Medicus. Journal of Psychopathology, Pacini Editore Srl, Via Gherardesca 1, 56121 Examples of the correct format for bibliographic citations: Pisa (Italy) – Tel. + 39 050 313011 – Fax + 39 050 3130300 Journal articles: [email protected] - www.pacinieditore.it Schatzberg AF, Samson JA, Bloomingdale KL, et al. Toward a biochemical Printed by Pacini Editore Srl - November 2015 classification of depressive disorders, X: urinary catecholamines, their me- Journal printed with total chlorine free paper and water varnishing tabolites, and D-type scores in subgroups of depressive disorders. Arch Gen The Publisher remains at the complete disposal of those with rights whom it was impossible to Psychiatry 1989;46:260-8. contact, and for any omissions. Subscribers’ data are treated in accordance with the provisions of the Legislative Decree, 30 Books: June 2003, n. 196 - by means of computers operated by personnel, specifically responsible. Kaplan HI, Sadock BJ. Comprehensive textbook of Psychiatry. Baltimore: These data are used by the Publisher to mail this publication. In accordance with Article 7 of the Legislative Decree no. 196/2003, subscribers can, at any time, view, change or delete their Williams & Wilkins 1985. personal data or withdraw their use by writing to Pacini Editore Srl, via A. Gherardesca 1, 56121 Chapters from books or material from conference proceedings: Ospedaletto (Pisa), Italy. Cloninger CR. Establishment of diagnostic validity in psychiatric illness: Robins Photocopies, for personal use, are permitted within the limits of 15% of each publication by following payment to SIAE of the charge due, article 68, paragraphs 4 and 5 of the Law April 22, and Guze’s method revisited. In: Robins LN, Barret JE, editors. The validity of 1941, No 633. Reproductions for professional or commercial use or for any other other purpose psychiatric diagnosis. New York: Raven Press 1989, p.74-85. other than personal use can be made following A WRITTEN REQUEST AND specific authoriza- tion in writing from AIDRO, Corso di Porta Romana, 108, 20122 Milan, Italy (segreteria@aidro. Acknowledgements and the citation of any grants or other forms of financial org - www.aidro.org). Informazioni per gli autori comprese le norme per la preparazione dei dattiloscritti

Il Giornale di Psicopatologia pubblica contributi redatti in forma di articoli di Termini matematici, formule, abbreviazioni, unità e misure devono confor- argomento monografico, news, articoli di aggiornamento in Psicofarmacologia marsi agli standard riportati in Science 1954;120:1078. clinica, forum, relativi a problemi di natura psichiatrica. I contributi devono I farmaci vanno indicati col nome chimico. Solo se inevitabile potranno essere essere inediti, non sottoposti contemporaneamente ad altra rivista, ed il loro citati col nome commerciale (scrivendo in maiuscolo la lettera iniziale del contenuto conforme alla legislazione vigente in materia di etica della ricerca. prodotto e inserendo il nome della relativa casa farmaceutica, la città e il Etica della ricerca. In caso di sperimentazioni sull’uomo, gli Autori devono paese di appartenenza). attestare che tali sperimentazioni sono state eseguite previa approvazione del Comitato Etico locale ed in accordo ai principi riportati nella Dichiarazione Agli Autori è riservata la correzione ed il rinvio (entro e non oltre 4 gg. dal di Helsinki (1983); gli Autori sono gli unici responsabili delle affermazioni ricevimento) delle sole prime bozze del lavoro. contenute nell’articolo e sono tenuti a dichiarare di aver ottenuto il consenso informato per la sperimentazione e per l’eventuale riproduzione di immagini. Norme specifiche per le singole rubriche Per studi su cavie animali, gli Autori sono invitati a dichiarare che sono state 1. Editoriali: sono intesi come considerazioni generali e pratiche su temi rispettate le relative leggi nazionali e le linee guida istituzionali. d’attualità, su invito del Direttore o dei componenti il Comitato. 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Devono essere riportati i primi 3 Autori, eventualmente seguiti da Il Giornale di Psicopatologia è trimestrale. I prezzi dell’abbonamento annuale et al. Le riviste devono essere citate secondo le abbreviazioni riportate su sono i seguenti: Italia: personale e istituzionale € 70,00; estero € 85,00. Index Medicus. Singolo fascicolo € 30,00. Esempi di corretta citazione bibliografica per: Le richieste di abbonamento e ogni altra corrispondenza relativa agli abbo- articoli e riviste: namenti vanno indirizzate a: Schatzberg AF, Samson JA, Bloomingdale KL, et al. Toward a biochemical Giornale di Psicopatologia, Pacini Editore Srl, Via Gherardesca 1, 56121 classification of depressive disorders, X: urinary catecholamines, their me- Pisa – Tel. 050 313011 – Fax 050 3130300 tabolites, and D-type scores in subgroups of depressive disorders. Arch Gen [email protected] – www.pacinimedicina.it Psychiatry 1989;46:260-8. libri: Finito di stampare presso le Industrie Grafiche della Pacini Editore Srl, Pisa - Novembre 2015 Kaplan HI, Sadock BJ. Comprehensive textbook of Psychiatry. Baltimore: Rivista stampata su carta TCF (Total Chlorine Free) e verniciata idro L’editore resta a disposizione degli aventi diritto con i quali non è stato possibile comunicare e Williams & Wilkins 1985. per le eventuali omissioni. capitoli di libri o atti di Congressi: I dati relativi agli abbonati sono trattati nel rispetto delle disposizioni contenute nel D.Lgs. del 30 giugno 2003 n. 196 a mezzo di elaboratori elettronici ad opera di soggetti appositamente Cloninger CR. Establishment of diagnostic validity in psychiatric illness: Robins incaricati. I dati sono utilizzati dall’editore per la spedizione della presente pubblicazione. Ai and Guze’s method revisited. In: Robins LN, Barret JE, editors. The validity of sensi dell’articolo 7 del D.Lgs. 196/2003, in qualsiasi momento è possibile consultare, modificare o cancellare i dati o opporsi al loro utilizzo scrivendo al Titolare del Trattamento: Pacini Editore psychiatric diagnosis. New York: Raven Press 1989, pp. 74-85. Srl, via A. Gherardesca 1, 56121 Ospedaletto (Pisa). Ringraziamenti, indicazioni di grant o borse di studio, vanno citati al termine Le fotocopie per uso personale del lettore possono essere effettuate nei limiti del 15% di ciascun fascicolo di periodico dietro pagamento alla SIAE del compenso previsto dall’art. 68, commi 4 e 5, della bibliografia. della legge 22 aprile 1941 n. 633. Le riproduzioni effettuate per finalità di carattere professionale, economico o commerciale o comunque per uso diverso da quello personale possono essere Le note, contraddistinte da asterischi o simboli equivalenti, compariranno effettuate a seguito di specifica autorizzazione rilasciata da AIDRO, Corso di Porta Romana n. nel testo, a piè di pagina. 108, Milano 20122, e-mail: [email protected] e sito web: www.aidro.org. Contents

Editorial Costituzione SOPSI GRUPPO GIOVANI e relativo Manifesto B. Dell’Osso, A. Di Giorgio, G. Di Lorenzo, S. Galderisi...... 225

Original articles Early hyperprolactinaemia in acute psychiatric inpatients: a cross-sectional study Iperprolattinemia precoce in pazienti ricoverati in spdc: uno studio trasversale G. Pigato, G.V.M. Piazzon, A. Di Florio, M. Ermani, T. Toffanin, G.I. Perini...... 226

Parental alienation syndrome or alienating parental relational behaviour disorder: a critical overview Sindrome da alienazione parentale o disturbo del comportamento relazionale genitoriale di tipo alienante: un’overview critica A. Siracusano, Y. Barone, G. Lisi, C. Niolu...... 231

MISM: Clinical and epidemiological data of a new Italian Public Mental Health Care Model in development “MISM” Modulo Integrato Sperimentale per la Salute Mentale: i dati clinici ed epidemiologici di una prospettiva assistenziale istituzionale in evoluzione E. Rosini, D. Pucci, G. Calabrò, P. Girardi...... 239

Metabolic syndrome in acute psychiatric inpatients: clinical correlates Sindrome metabolica in pazienti ricoverati in SPDC: correlati clinici F. Solia, G. Rosso, G. Maina...... 246

Exploratory factor analysis of the Mini instrument for the observer rating according to ICF of Activities and Participation in Psychological disorders (Mini-ICF-APP) in patients with severe mental illness Analisi fattoriale esplorativa del Mini instrument for the observer rating according to ICF of Activities and Participation in Psychological disorders (Mini-ICF-APP) in pazienti con disturbi mentali gravi P. Rucci, M. Balestrieri...... 254

Can we modulate obsessive-compulsive networks with neuromodulation? Neuromodulazione dei network ossessivo-compulsivi: è possibile? S. Pallanti, G. Grassi, A. Marras, E. Hollander...... 262

Treatment of resistant mood and schizoaffective disorders with electroconvulsive therapy: a case series of 264 patients Trattamento dei disturbi resistenti dell’umore e schizoaffettivi con la terapia elettroconvulsiva: una casistica di 264 pazienti O. Benzoni, G. Fàzzari, C. Marangoni, A. Placentino, A. Rossi...... 266

Strategies to implement physical health monitoring in people affected by severe mental illness: a literature review and introduction to the Italian adaptation of the Positive Cardiometabolic Health Algorithm Strategie per implementare il monitoraggio della salute fisica in soggetti affetti da disturbi psichiatrici gravi: revisione della letteratura e presentazione dell’adattamento italiano del Positive Cardiometabolic Health Algorithm M. Ferrara, F. Mungai, M. Miselli, D. Shiers, J. Curtis, F. Starace...... 269

Assessment and instruments in psychopathology Validation of the Italian Version of the Aberrant Salience Inventory (ASI): a New Measure of Psychosis Proneness Validazione della versione italiana dell’Aberrant Salience Inventory (ASI): una nuova misura per la vulnerabilità alla psicosi L. Lelli, L. Godini, C. Lo Sauro, F. Pietrini, M. Spadafora, G.A. Talamba, A. Ballerini...... 281

Italian version of the “Specific Level of Functioning” Versione italiana della “Specific Level of Functioning” C. Montemagni, P. Rocca, A. Mucci, S. Galderisi, M. Maj...... 287

Autism Rating Scale (ARS) – Italian version Scala di Valutazione dell’autismo – versione italiana M. Ballerini, G. Stanghellini, M. Chieffi, P. Bucci, P. Punzo, G. Ferrante, N. Merlotti, A. Mucci, S. Galderisi...... 297 Editorial

Costituzione SOPSI GRUPPO GIOVANI e relativo Manifesto

Nel corso della diciannovesima edizione del Congresso con le attività della SOPSI. Unitamente ai primi compo- della Società Italiana di Psicopatologia (SOPSI), svoltosi nenti individuati dal Direttivo SOPSI, possono fare doman- a Milano dal 23 al 26 febbraio 2015, veniva istituita il da di partecipazione alla SOPSI-GG tutti coloro che siano 24 febbraio 2015 da parte del Presidente della Società regolarmente iscritti alla SOPSI e che presentino i suddetti prof. A. Carlo Altamura, per conto del Direttivo SOPSI, la requisiti, previo invio di domanda e C.V. ai delegati na- sezione denominata “SOPSI GRUPPO GIOVANI” (SOPSI- zionali. La partecipazione alla SOPSI-GG è gratuita. GG), avente come rappresentante del Direttivo stesso in La SOPSI-GG si consulta attraverso 3 riunioni telemati- tale area la prof.ssa Silvana Galderisi. Nel corso dell’e- che, una per quadrimestre, nel corso dell’anno e nel cor- vento veniva proposta dal prof. Altamura e dalla prof.ssa so dell’assemblea annuale, durante il Congresso SOPSI, Galderisi una serie preliminare di nominativi di medici elegge i 3 delegati nazionali con un mandato di un anno specializzandi, dottorandi e specialisti in Psichiatria e rinnovabile al massimo per un altro anno. La SOPSI-GG nell’area delle Neuroscienze, di età anagrafica non supe- comunica regolarmente al rappresentante del Direttivo riore al 40° anno, che si erano distinti nell’attività della SOPSI le minute delle riunioni telematiche, le proposte ricerca clinica e scientifica. La lista dei nomi, qui in se- e le iniziative prese nel corso dell’assemblea nazionale. guito riportata, voleva costituire unicamente una semplice In specifico, gli obiettivi che il gruppo si propone sono: formazione di lavoro iniziale, caratterizzata da una buona • migliorare la comunicazione tra gli organi direttivi del- rappresentanza sul territorio nazionale, da ampliarsi, suc- la Società e i giovani psichiatri; cessivamente, attraverso l’inclusione di nuovi membri con • promuovere iniziative volte a individuare i principali caratteristiche compatibili con quelle richieste dal gruppo. bisogni formativi dei giovani psichiatri; Nel corso della presentazione venivano delineati i primi • favorire l’individuazione e la discussione di tematiche obiettivi per la SOPSI-GG, individuati dal Direttivo, nella specifiche della formazione continua che risultino di par- presentazione di Simposi nel corso delle edizioni congres- ticolare utilità nei primi anni della carriera professionale; suali annuali della SOPSI, lo sviluppo di progetti di ricerca • promuovere forme innovative di formazione (e-lear- così come di altre iniziative volte a promuovere l’interazione ning) e più in generale di comunicazione; tra i membri della SOPSI-GG e il Direttivo SOPSI. • promuovere la partecipazione dei giovani ricercatori Dietro richiesta della prof.ssa Galderisi, al termine dell’in- alle edizioni congressuali della SOPSI attraverso ini- contro veniva svolta una prima assemblea da parte dei ziative promozionali (incentivi, premi e riconoscimen- presenti che portava all’individuazione di tre delegati del- ti) volte a facilitare l’iscrizione dei membri alla Società la SOPSI-GG, con mandato di un anno, nelle persone di e al Congresso SOPSI, l’invio di abstract congressuali e Bernardo Dell’Osso (Milano), Annabella Di Giorgio (Bari) e l’invio di contributi al Giornale della Società; Giorgio Di Lorenzo (Roma). Veniva, altresì, deciso nel corso • organizzare proposte di Simposio SOPSI-GG da pro- dell’assemblea la programmazione di un breve Manifesto porre al Direttivo sia in relazione alle edizioni con- che raccogliesse i principali obiettivi del nuovo gruppo. Do- gressuali annuali della SOPSI che al di fuori di esse; po successiva consultazione telematica dei membri apparte- • promuovere l’interazione dei giovani ricercatori sul nenti alla SOPSI-GG veniva redatto il seguente documento: territorio nazionale; • favorire lo sviluppo di progetti di ricerca per richieste Manifesto SOPSI GRUPPO GIOVANI di finanziamenti nazionali e internazionali da svolger- La SOPSI GRUPPO GIOVANI (SOPSI-GG), creata nel cor- si sotto l’egida della SOPSI. so della 19a Edizione del Congresso della SOPSI a Milano è formata da medici specializzandi e specialisti in Psichia- Milano, 26 Febbraio 2015 tria, dottorandi e dottorati nell’area della Psichiatria e delle Neuroscienze che abbiano compiuto non oltre il 40° anno Bernardo Dell’Osso1, Annabella Di Giorgio1, di età e che presentino uno specifico profilo d’interesse nel Giorgio Di Lorenzo1, Silvana Galderisi2 campo della ricerca clinica e delle neuroscienze, in linea 1 Delegati SOPSI-GG; 2 Coordinatrice SOPSI-GG per il Direttivo

Composizione SOPSI-GG: Bernardo Dell’Osso (Milano), Massimiliano Buoli (Milano), Annabella Di Giorgio (Bari), Giorgio Di Lorenzo (Roma), Michele Ribolsi (Roma), Felice Iasevoli (Napoli), Carmine Tomasetti (Napoli), Maria Signorelli (Catania), Giuseppe Minutolo (Catania), Diego Primavera (Cagliari), Andrea Aguglia (Torino), Cristiana Montemagni (Torino), Valeria Giannunzio (Padova), Enrico Collantoni (Padova), Alessio Monteleone (Napoli), Eleonora Gattoni (Novara), Carla Gramaglia (Novara), Stefano Barlati (Brescia), Marcello Chieffi (Napoli), Panariello Fabio (Brescia), Wilmer Mostacciuolo (Siena), Marta Valdagno (Siena).

Journal of Psychopathology 2015;21:225 225 Original article

Early hyperprolactinaemia in acute psychiatric inpatients: a cross-sectional study Iperprolattinemia precoce in pazienti ricoverati in spdc: uno studio trasversale

1 1 2 3 3 1,3 G. Pigato , G.V.M. Piazzon , A. Di Florio , M. Ermani , T. Toffanin , G.I. Perini 1 Department of Neurosciences, Section of Psychiatry, University-Hospital of Padova, Padova, Italy; 2 Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK; 3 Department of Neurosciences, Section of Neurology, University-Hospital of Padova, Padova, Italy; 4 Department of Psychiatry, ULSS 7, Pieve di Soligo, Treviso, Italy

Summary Results About 2 in 3 individuals treated with antipsychotics had hyper- Objectives prolactinaemia. Treatment with antipsychotics, particularly risp- Hyperprolactinaemia is an important adverse effect of many drugs. eridone (p = 0.002), and young age (p<0.005) were associated Few naturalistic studies have compared rates of hyperprolactinae- with hyperprolactinaemia. We did not find any association be- mia across psychotropic medications, especially antidepressants. In tween antidepressants and hyperprolactinaemia (p = 0.07). this cross-sectional study, we aimed to: 1) assess the prevalence and severity of hyperprolactinaemia in a sample of individuals with Conclusions severe acute psychiatric illnesses, and 2) identify the demographic Hyperprolactinaemia is a common and early phenomenon and clinical factors that might influence levels of prolactinaemia. among individuals treated for acute psychiatric disorders, especially in younger patients and women. Methods 225 individuals were consecutively recruited. Individuals with Key words any medical conditions and other not psychopharmacologi- Early hyperprolactinaemia • Psychotropic medications • Psychiatric dis- cal drugs known to induce hyperprolactinemia were excluded. orders Blood samples were collected prior to breakfast and medication administration. Prolactin levels were measured by an electro- chemiluminescent immunoassay.

Introduction reuptake inhibitors (SSRIs), may cause HP although to a lesser degree. Most studies have focused on these three Hyperprolactinaemia (HP) refers to an elevation of the antidepressant categories 10 4. Pharmacodynamic mecha- level of the hormone prolactin (PRL) in the blood and is nisms such as serotoninergic receptor modulation 11 and a frequent adverse effect of psychopharmacological treat- GABAergic stimulation 12 have been suggested. ment. HP may have clinical consequences that are more Few naturalistic studies have compared the rates of HP detectable in the short term (reproductive and sexual dys- across psychotropic medications. Most studies have exam- function) than in the long term (osteoporosis, weight gain, ined antipsychotics 13 whereas there are few and weak data cardiovascular disorders and an increased risk of breast or on antidepressants which are from small samples or case 1 2 endometrial cancer) . Antipsychotics which are known to reports/series 10. The results are also difficult to compare be- be the most common cause of pharmacological HP have cause of methodological differences in the units of meas- different propensities to induce HP 3 4. Several mechanisms urement of PRL, definition of HP (categorical or continu- by which antipsychotics cause HP have been proposed 5: ous, different cut-offs), sampling, sample size and a lack 6 1) strong binding to D2 receptors (expressed by K-off) ; 2) of information about pharmacological treatment (add-on 14 5HT2/D2 receptor antagonism, which exerts a balanced ef- medications, dosages) . Given these assumptions, in the fect on PRL release 7; 3) permeation of the haematoence- present study, we sought to: 1) measure the prevalence and 8 9 phalic barrier ; and 4) partial agonism of D2 receptors . severity of HP in a sample of acute psychiatric patients, and Additionally, antidepressants, mainly tricyclics, mono- 2) identify the demographic and clinical factors that might amine oxidase inhibitors (MAOIs) and selective serotonin influence the elevation of PRL levels.

Correspondence Tommaso Toffanin, Department of Psychiatry, ULSS 7 Pieve di Soligo, via Brigata Bisagno 4, 31015 Conegliano, Treviso, Italy • Tel. +39 0438 668362 • Fax +39 0438 663728 • E-mail: [email protected]

226 Journal of Psychopathology 2015;21:226-230 Early hyperprolactinaemia in acute psychiatric inpatients: a cross-sectional study

Methods Table I. Study population Demographic and clinical characteristics of patients (N = 225). Caratteristiche demografiche e cliniche dei pazienti (N = 225). Between 2010 and 2011, 225 DSM-IV-diagnosed patients were included in this cross-sectional study. The par- N (%) Mean ± SD ticipants were consecutively recruited in the Psychiatric Gender Unit at the University-Hospital of Padua, Italy. The inclu- Men 102 (45.4) sion criteria were: i) age of 18 years old or greater and ii) Women 123 (54.7) same duration of treatment (1 week ± 1 day) with antip- Age (years) sychotics, antidepressants or mood stabilizers, either in Men 44.4 ± 16.2 Women 50.6 ± 15.5 monotherapy or in combination. The patients were excluded if they had medical conditions or were receiving Menopausal status Premenopausal 64 (52) medications known to cause HP. Postmenopausal 59 (48) Written informed consent was obtained from all patients, Diagnoses according to the local institutional policy. Medications were Psychotic Disorders 121 (53.8) administered by nursing hospital staff to ensure adherence. Depressive Disorders 47 (20.9) To compare dosages across different antipsychotics, daily Bipolar Disorders 32 (14.2) Personality Disorders 18 (8) dosages were transformed into haloperidol equivalent Others Disorders 7 (3.1) doses 15. All patients received a routine laboratory assess- Duration of illness (years) 14.6 ± 3.5 ment (including PRL serum level testing). Blood samples were collected from the patients between 8:00 a.m. and Medications APs 167 (74.2) 8:30 a.m., prior to breakfast and medication administration. PRL levels were measured by an electrochemilumi- FGAs 31 (13.8) nescent immunoassay (ECLIA Cobas 6000). Haloperidol 17 (7.6) Our laboratory set serum PRL above the upper limit of Perphenazine 6 (2.7) Promazine 8 (3.6) normal to 25 ng/mL for women and 15 ng/mL for men. The degree of HP was also considered in terms of severity SGAs 119 (52.9) (> 47 ng/mL), based on other studies 13 16. Olanzapine 36 (16) Risperidone 33 (14,7) Quetiapine 28 (12.4) Statistical analysis Aripiprazole 10 (4.4) The Kolmogorov-Smirnov method was used to test for Clozapine 12 (5.3) the normality of variables. A Student’s t-test and Mann- 2 APs (FGA + SGA) 17 (7.5) 4.98 ± 3.03 Whitney U test were used for normally distributed and ordinal variables, respectively. For categorical variables, APs dosage (mg/day) a chi square test was used. To identify the truly independ- ADs 70 (31.1) ent risk factors for the presence of HP, logistic regression SSRIs 40 (17.8) was performed, and variables significantly related to the SNRIs 24 (10.7) presence of HP in the univariate analyses were included Other ADs 6 (2.7) in the model. The significance level was set at p<0.05. APs + ADs 43 (19.1)

MSs 81 (36) Results Lithium 15 (6.7) Valproate 60 (26.7) Demographic and clinical characteristics Other MSs 6 (2.7) The characteristics of the sample are presented in Table I. Most patients (56.8%) had PRL blood levels above the up- Prolactin level (ng/mL) 32.7 ± 31.9 per limit of normal (15 ng/mL for men and 25 ng/mL for Range ( 0,6 – 183,8) women). The mean PRL level was 32.7 ng/mL (SD ± 31.9; Hyperprolactinemia 128 (56.8) range 0.6-183.8). Men (> 15 ng/mL) 75 (33.3) Women (> 25 ng/mL) 53 (23.5) Univariate analysis HP severity ≤ 47 ng/mL > 47 ng/ml HP was significantly more prevalent in younger (mean All 83 45 age 44.4 ± 16.2 years) than in older (52.45 ± 16.1 years) Men 61 (81,3%) 14 (18,7%) individuals (p < 0.005), in men (73%, N = 75) than in Women 22 (41,5%) 31 (58,5%)

227 G. Pigato et al.

women (43%, N = 53) (p < 0.005) and in premenopausal gistic regression. All variables except diagnosis were sig- (53%, N = 34) than in postmenopausal (32%, N = 19) nificantly associated with HP, and the regression function women (p = 0.020). Among women, 58% (N = 31) had predicted 71% (95% CI 65-77%) of all cases of HP. PRL levels above 47 ng/mL (p < 0.005). HP was significantly more prevalent in patients with diagnosis of psy- Discussion chosis (71.9%) (p < 0.005) and in individuals treated with antipsychotics (65%, N = 108) (p < 0.005). HP was also In our sample, the overall prevalence rate of HP was high associated with a higher daily antipsychotic dose (mean (57%), and was even higher among patients treated with haloperidol equivalent daily dose 5.33 ± 3.05 mg/day vs. antipsychotics (65%). Our rates were similar to those val- 4.33 ± 39 mg/day, p = 0.02). When the severity of HP was ues reported in previous studies, in which HP was present considered, women showed significantly higher levels of in 28% 2 to 69% 17 of patients on antipsychotic treatment. HP than men (p < 0.005). Younger age was associated with HP for both genders. Other variables were not associated with HP (particular- This result is frequently reported in the literature 18. We ly, the combination of two antipsychotics or one antipsy- found higher rates of HP in men than in women. This re- chotic and antidepressants; p = 0.34). sult is not in accordance with the findings of other studies Prevalence and degree of HP according to the type of which showed higher rates of HP among women 19 20. This single antipsychotic are shown in Table II. Risperidone discrepancy may be related to different laboratory criteria showed the highest prevalence of HP (90.9%) (p = 0.002), for defining HP and the different duration of treatment. and 16 of 30 risperidone-medicated patients showed PRL When the severity of HP was considered, women pre- levels above 47 ng/mL (p < 0.03). Among other second sented a more severe degree of HP, in agreement with the generation antipsychotics (SGAs), HP was under 47 ng/ results of other studies 21. mL in the vast majority of cases. The combination of an- Our study confirmed that HP was more prevalent in tipsychotics and antidepressants/mood stabilisers was premenopausal than in postmenopausal women, in ac- also not significantly associated with HP (p = 0.07). cordance with the findings of other studies 18. In women, We found HP in 20 patients not treated with antipsychot- reproductive age has been associated with a more pro- ics; only two of 20 cases were treated with antidepressants. nounced risk of HP due to oestrogens having an indirect stimulating effect on PRL release by inhibiting hypotha- Multivariate analysis lamic dopamine synthesis and a reduction in the number 22 Variables significantly related to HP in univariate analy- of pituitary D2 receptors . sis (age, gender, diagnosis and antipsychotic treatment) Our study confirmed the strong association between were used as independent variables in a multivariate lo- HP and the use of antipsychotics 4 23. We did not ob-

Table II. The prevalence of hyperprolactinaemia according to the type of pharmacological treatment. La prevalenza dell’iperprolattinemia a seconda del tipo di trattamento farmacologico.

Drug HP (>15/25 ng/mL) HP (≤ 47 ng/mL) HP (> 47 ng/mL) N % N % N % APs 108 64.7 70 64.8 38 35.2 FGA monotherapy 22 70.9 17 77.3 5 22.7 SGA monotherapy 73 61,3 45 61.6 28 38,4 Risperidone 30 90,9 14 46.7 16 53.3 Olanzapine 22 61.1 14 63.6 8 36.4 Quetiapine 10 35.7 7 70 3 30 Clozapine 7 58.3 7 100 Aripiprazole 4 40 4 100 - - 2 APs (FGAs + SGAs) 13 76.4 8 61.5 5 31.5 MSs and/or ADs 20 34.5 13 65 7 35 HP: hyperprolactinemia; APs: Antipsychotics; FGAs: First Generation Antipsychotics; SGAs: Second Generation Antipsychotics; MSs: mood stabilisers; ADs: antidepressants.

228 Early hyperprolactinaemia in acute psychiatric inpatients: a cross-sectional study

serve significant differences when antipsychotics were Conflict of interests administered in monotherapy or in combination with None. another antipsychotics or antidepressants. We also found that a higher dosage may exert an influence on References elevating PRL levels, consistent with the findings of previous studies 17. 1 Henderson DC, Doraiswamy PM. Prolactin-related and met- It is noteworthy that the association of first-generation abolic adverse effects of atypical antipsychotic agents. J Clin antipsychotics (FGAs) with high rates of HP has been Psychiatry 2008;69. confirmed 17 21. Olanzapine, clozapine, aripiprazole and 2 Hummer M, Malik P, Gasser R, et al. Ostepoporosis in pa- quetiapine were also associated with HP, even though tients with schizophrenia. Am J Psychiatry 2005;162:162-7. these drugs have been known to induce only transient 3 Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and milder PRL elevation by different pharmacodynam- and treatment of hyperprolactinemia: an Endocrine So- ic properties 24 25. Aripiprazole, can even reduce HP 26. ciety clinical practice guideline. J Clin Endocrinol Metab Risperidone was confirmed to be the most PRL-elevating 2011;96:273-288. medication 14 16. This drug has been reported to induce an 4 Molicht ME. Drugs and prolactine. Pituitary 2008;11:209-18. early and persistent rise in PRL levels, even if tolerance 5 Byerly M, Suppes T, Tran QV, et al. Clinical implications of occurs in the long term 27. antipsychotic-induced hyperprolactinaemia in patients with Interestingly, we did not find any association between schizophrenia spectrum or bipolar spectrum disorders. J HP and antidepressants. This result confirms that antide- Clin Psychoparmacol 2007;27:639-59. pressants may exert only an occasional PRL-elevating ef- 6 Maguire GA. Prolactin elevation with antipsychotics medi- fect 10. Out of 128 subjects with HP, 20 were not treated cations: mechanism of action and clinical consequences. J with antipsychotics. Clin Psychiatry 2002;63:56-62. These HP patients were taking mostly mood stabilisers 7 Meltzer HI, Bastanil B, Ramirez L, et al. Clozapine: new re- and antidepressants in only two cases. This result may be search on efficacy and mechanism of action. Eur Arch Psy- explained by other, unmeasured factors such as recent chiatry Clin Neurosci 1989;238:332-9. antipsychotics which were mostly not available for ret- 8 Kapur S, Langlois X, Vinken P, et al. The differential effects of rospective quantification, hospitalisation or environmen- atypical antipsychotics on prolactin elevation are explained tal stress. In fact, stress is a condition known to induce by their blood-brain disposition: a pharmacological analysis HP 3 23. Further studies may include tools such as rating in rats. J Pharmacol Exp Ther 2002;302:1129-34. scales to measure these factors. 9 Bushe C, Shaw M, Peveler RC. A review of the association Lastly, in the present study, detection of HP was per- between antipsychotic use and hyperprolactinaemia. J Psy- formed by PRL sampling after one week of pharmaco- chopharmacol 2008;22:46-55. logical treatment, regardless of clinical symptoms. Our 10 Coker F, Taylor D. Antidepressant-induced hyperprolactine- results are consistent with the findings of previous natu- mia. Incidence, mechanism and management. CNS Drugs ralistic cross-sectional studies that used different (mostly 2010;24:563-74. longer) times for the stabilisation of pharmacological 11 Rittenhouse PA, Levy AD, Li Q, et al. Neurons in the hypo- treatment 19 28. thalamic paraventricularnuclaus mediate the serotoninergic Clinical guidelines do not provide precise recommenda- stimulation of prolactin secretion via 5-HT1C/2 receptor. tions on measuring PRL which is suggested only in the Endocrinology 1993;133:661-7. presence of clinical symptoms 29 30. Our study seems to 12 Emiliano AB, Fudge JL. From galactorrhea to osteopenia: indicate that systematic and early examination of PRL se- rethinking serotonin-prolactin interactions. Neuropsychop- rum levels might be a preliminary tool to identify HP and harmacology 2004;29:833-46. to more promptly manage emergent HP side effects in 13 Bushe C, Yeomans D, Floyd T, et al. Categorical prevalence acutely treated patients. and severity of hyperprolactinaemia in two UK cohorts of patients with severe mental illness during treatment with antipsychotics. J Psychopharmacol 2008;22:56-62. Conclusions 14 Peuskens J, Pani L, Detraux J, et al. The effects of novel and These preliminary findings suggest that during the early newly approved antipsychotics on serum prolactin levels: a stage of pharmacological treatment HP is very frequent comprehensive review. CNS Drugs 2014;28:421-4. in patients who are younger, women of reproductive age 15 Andreasen NC, Pressler M, Nopoulos P, et al. Antipsychot- and undergoing treatment with risperidone. Future pro- ics dose equivalents and dose-year: a standardized method spective studies examining these factors are needed to for comparing exposure to different drugs. Biol Psychiatry evaluate the causal relationship with HP and its clinical 2010;67:255-62. symptoms in both the short and long terms. 16 Bushe C, Shaw M. Prevalence of hyperprolactinaemia in a

229 G. Pigato et al.

naturalistic cohort of schizophrenia and bipolar outpatients 23 MilanoW, De Rosa M, Milano L, et al. Antipsychotics and during treatment with typical and atypical antipsychotics. J prolactinemia: biological regulation and clinical aspects. Psychopharmacol 2007;21:768-73. Giorn Ital Psicopat 2010;16:228-33. 17 Montgomery J, Winterbottom E, Jessani M, et al. Prevalence 24 Citrome L. Current guidelines and their recommendations of hyperprolactinemia in schizophrenia: association with for prolactin monitoring in psychosis. J Psychopharmacol typical and atypical antipsychotic treatment. J Clin Psychia- 2008;22:90-7. try 2004;65:1491-8. 25 Hamner M. The effects of atypical antipsychotics on serum 18 Kinon BJ, Gilmore JA, Liu H, et al. Hyperprolactinemia in re- prolactin levels. Ann Clin Psychiatry 2002;14:163-73. sponse to antipsychotic drugs: characterization across compar- 26 Fagiolini A, Goracci A, Castrogiovanni P. Endocrine and ative clinical trials. Psychoneuroendocrinology 2003;28:69-82. metabolic effects of medications used for bipolar disorder. 19 Kinon BJ, Gilmore JA, Liu H, et al. Prevalence of hyperpro- Giorn Ital Psicopat 2008;14:367-81 lactinemia in schizophrenic patients treated with conven- 27 Eberhard J, Lindstrçm E, Holstad M, et al. Prolactin level dur- tional antipsychotic medications or risperodone. Psycho- ing 5 years of risperidone treatment in patients with psy- neuroendocrinology 2003;28:55-68. chotic disorders. Acta Psychiatr Scand 2007;115:268-76. 20 Vaselinovic T, Schorn H, Vernaleken I, et al. Impact of dif- 28 Smith S, Wheeler MJ, Murray R, et al. The effects of an- ferent antidopaminergic mechanisms on the dopaminer- tipsychotic-induced hyperprolactinaemia on the hypo- gic control of prolactin secretion. J Clin Psychopharmacol thalamic-pituitary-gonadal axis. J Clin Psychopharmacol 2011;31:214-20. 2003;22:109-14. 21 Johnsen E, Kroken RA, Abaza M, et al. Antipsychotic-in- 29 Lehamn AF, Lieberman JA, Dixon LB, et al. Practice guide- duced hyperprolactinemia. A cross sectional Survey. J Clin lines for the treatment of patients with schizophrenia, sec- Psychopharmacol 2008;28:686-90. ond edition. Am J Psychiatry 2004;161:1-56. 22 Halbreich U, Kinon BJ, Gilmore JA, et al. Elevated prolactin 30 Walters J, Jones I. Clinical questions and uncertainty-prolac- level in patients with schizophrenia. Mechanism and related tin measurement in patients with schizophrenia and bipolar adverse effects. Psychoneuroendocrinology 2003;28:53-67. disorder. J Psychopharmacol 2008;22:82-9.

230 Original article

A. Siracusano, Y. Barone, G. Lisi, C. Niolu Dipartimento di Medicina dei Sistemi, Università di Roma Tor Vergata, UOC di Psichiatria e psicologia clinica, Policlinico Tor Vergata, Roma, Italia

Summary Results A total of 28 articles and books were appropriate for this review. Objective The studies included raised many fundamental questions such Parental alienation is very common in conflictual separations as the scientific validity of PAS, the proposal of specific diagnos- and is a serious problem in most parts of the world. In 50% tic criteria and the importance of an accurate diagnosis. Find- of separations and in one-third of divorces a child under 18 is ings from studies that met inclusion criteria in our review are involved. One of the major problems in these cases is when chil- presented, suggesting new clinical perspectives and raising new dren reject a parent after divorce. In conflictual separations a real questions concerning assessment and treatment. psychopathology, defined as parental alienation syndrome (PAS) in 1985, can develop. In recent years, a growing interest in this Conclusion syndrome has been seen in the international scientific commu- The theme of parental alienation is currently the subject of im- nity: several studies have been carried out and the necessity for portant research and debate. Based on the research carried out, a more accurate definition of PAS has been considered beneficial we could state that parent alienation does not correspond to a because courts, scientific and clinical practice are interested in “syndrome” or a specific individual psychic “disorder”. It can this syndrome. In order to understand parental alienation bet- better defined as a dysfunctional family relation model deter- ter, our investigation aims to identify which findings in published mined by the excluding or “alienating” parent, the excluded or studies may be useful to clinical practice involving both parents “alienated” parent and the child, each member of this triad with his/her own responsibilities and contribution. The explanation of and children. this disorder has its own validity, but thorough research to clarify its features, (e.g. duration and intensity of symptoms) should be Methods conducted, otherwise it could be instrumentally used in litiga- Our study systematically reviewed all publications in the MED- tions. Further systematic and large-scale studies of parental al- LINE/PubMed database searching for the terms “parental aliena- ienation are needed that take into account the issues discussed tion”, “parental alienation syndrome”, or “parental alienation and proper objective diagnostic criteria should be defined for disease” as keywords. We included studies and books that were scrupulous diagnosis and valid treatment. published online between 1985 and 2015, included original data or reviews and involved assessment and/or diagnosis and/ Key words or treatment of PAS. This assessment will reveal strengths and weaknesses in the current PAS literature; moreover, we present Alienation • parental alienation • denigration • parent-child relational suggestions for improving the refinement of the literature. problems

Introduction were court divorces, and the legal dispute usually involved Parental Alienation is very common in conflictual separa- child custody 1. One of the major problems in these cases tions and is a serious problem in most parts of the world. is when children reject a parent after divorce 2. In conflict- Nearly half (48.7%) of separations and one-third (33.1%) ual separations, a real psychopathology, defined as pa- of divorces concern marriages with at least one child un- rental alienation syndrome (PAS) in 1985, can develop 3. der 18. The number of minor children who were placed In recent years, a growing interest in this subject has been in foster care in 2012 amounted to 65,064 in separations seen in the international scientific community: several and 22,653 in divorces. In separations, 54.5% of children studies have been carried out and the necessity for a more in foster care were under 11 years of age; 20% of cases accurate definition of PAS has been considered because

Correspondence Ylenia Barone, UOC di Psichiatria, via Nomentana 1362, 00137 Roma, Italia • E-mail: ylenia.barone@ hotmail.it

Journal of Psychopathology 2015;21:231-238 231 A. Siracusano et al.

courts, scientific and clinical practice are interested in ienation is that the child – usually over a very contentious this syndrome. PAS is the subject of a heated debate in divorce – stipulates an alliance with one of the parents both the scientific and legal fields. In particular, while (the preferred parent) and rejects the relationship with the attention is paid to the reliability and scientific validity of other parent (the rejected parent) without legitimate jus- the syndrome, there is also the risk of the disorder being tification” (Fig. 1) 5 6. exploited in legal disputes or in the media. This definition was later clarified by Cavedon and Magro In order to understand parental alienation better, our in- in 2010, who defined the following criteria: vestigation aims to identify which findings in published 1. the child is allied with one of the parents and rejects the studies may be useful to clinical practice with both par- relationship with the other parent without any legiti- ents and children. mate justification, usually in the context of a conflictual separation that can involve a child custody dispute; Method 2. the child shows the following behaviour: a) constant rejection of a parent that can become a real campaign This article provides an up-to-date critical review of sci- of denigration; b) use of futile, weak or absurd ration- entific articles on parental alienation. We will begin by alisations, in order to criticise the rejected parent per- reviewing the criteria for its definition, postulated patho- sistently; genesis and subtypes in order to lay the foundation for 3. the child shows at least two of the following behav- understanding PAS; next, we will delineate how PAS is iours and attitudes: a) lack of ambivalence; b) phe- placed in the psychiatric classification, including its re- nomenon of the independent thinker; c) automatic lationship with official diagnostic categories of psycho- support of the alienating parent; d) no guilty feelings pathology. for not respecting and not accepting the feelings of the Our study systematically reviewed all publications in alienated parent; e) presence of borrowed scenarios; the MEDLINE/PubMed database searching for the terms f) spread of animosity towards the alienated parent’s “parental alienation”, “parental alienation syndrome”, or extended family 7. “parental alienation disease” as keywords. We included studies and books that: (i) were published online between PAS: Features 1985 and 2015, (ii) included original data or reviews and (iii) were concerned with assessment and/or diagnosis Gardner described PAS as a preoccupation by the child and/or treatment of PAS. Consequently, we excluded with criticism and deprecation of a parent, and stated publications that concerned child maltreatment or abuse that PAS occurs when, in the context of child custody dis- not acknowledged as PAS. In the end, we selected rel- putes, one parent deliberately or unconsciously attempts evant studies according to the inclusion criteria specified to alienate a child from the other parent 4 8 9. above. A total of 28 articles and books were appropriate The author described eight symptoms: for this review. This assessment will reveal strengths and Campaign of denigration: It involves the active partici- weaknesses in the current PAS literature; moreover, we pation of the child to the disparaging campaign against present suggestions for improving the refinement of the the target spouse, without scolding or punishment by the literature. alienated parent. Weak, frivolous, and absurd rationalisations for the child’s PAS: definition criticism of the targeted parent: When they are asked to report specific incidences or explicit examples which PAS was defined for the first time in 1985 by Richard Gard- support their accusations, they are unable to document ner as a disorder that primarily arises in the context of court credible, significant, or factual examples. divorces that involve a dispute over the custody of the chil- Lack of ambivalence: very likely, PAS children will report dren. Its primary manifestation is the unjustified campaign a long list of deficits about their targeted parent while of denigration by the child of one parent. In the words of minimising or refuting any positive attribute or redeeming the author, PAS can be described as “a childhood disor- quality of that parent. der, which arises almost exclusively in the context of child The independent thinker phenomena: the child claims custody disputes. Its primary manifestation is the child’s to be independent in making decisions and judgments campaign of denigration against a parent that results from about the alienated parent, rejecting accusations of being the combination of a parent’s programming (brain wash- a weak and passive person. ing) indoctrinations and the child’s own contributions to Reflexive support of the alienating parent: the phenom- the vilification of the target parent” 3 4. enon of the ‘’identification with the aggressor” can be More recently Bernet defined PAS as PAD, i.e. parental connected to this. The child being weak supports the al- alienation disorder. “The essential feature of parental alienating parent because of his/her power.

232 Parental alienation syndrome or alienating parental relational behaviour disorder: a critical overview

Figure 1. Definitions according to Bernet, 2008 6. Definizioni secondo Bernet, 2008 6.

Absence of guilt over cruelty to or exploitation of the al- transitional difficulties at the time of visitation; in severe ienated parent: Child victims of the alienating parent’s PAS, all of the eight characteristic symptoms are present campaign of denigration do not feel guilt or empathy to- with severe intensity, and the children refuse to have con- wards the victim parent and do not feel a decrease in tact with the alienated parents 8-10. their self-esteem, which is part of the guilt. In clinical cases of mild PAS psychological intervention Presence of borrowed scenarios: Children use phrases is not usually needed. However, it is important to raise and expressions learned from the adults’ vocabulary and awareness among relevant experts to avoid incorrect as- relate events they have never lived or cannot know about, sessment and incorrect handling of situations, and it is but that are part of the smear campaign. essential to reassure the alienating parent about the pos- Spread of the child’s animosity to the extended family sibility of keeping custody of child. of the alienated parent: PAS children also inexplicably In cases of moderate PAS, which are the most common, reject those relatives they had previously had a loving the court should establish a system of effective sanctions relationship with and turn hostile to them. to be inflicted on the alienating parent, if he/she tries to Later, Gardner 4 added four more diagnostic criteria: sabotage the therapeutic program agreed on with the psy- • difficulties of transition when visiting the non-custo- chotherapist. dial parent; In cases of severe PAS, it is necessary, according to Gard- • behaviour of the child during visits or periods of stay ner, to enact stringent measures that provide for the trans- at the alienated parent’s; fer of primary custody to the alienated parent, and simul- • bond with the alienating parent; taneously placing the child’s residence in his/her house. • bond with the alienated parent (before the start of the If this is the case, it is possible to gradually transfer the process of alienation). child to the alienated parent’s house by arranging some Depending on the intensity of the symptoms, Gardner “transitional accommodation” (e.g. the home of a friend, established three levels of PAS severity: mild, moderate, of a relative, community housing, or hospitalisation) 10 11. and severe. In mild PAS, alienation is relatively superficial, and children mostly cooperate with visitation but are intermittently critical and disgruntled with the victimised DSM-5 and parental alienation parent; in moderate PAS, alienation is more intense, and In the DSM-5 the expression “parental alienation” is not children are more disruptive and disrespectful. There are present, and the phenomenon is called differently. Paren-

233 A. Siracusano et al.

tal alienation can, in fact, be framed within the category A. The child – whose parents are usually involved in a of Relational Problems. The DSM-5 defines Relational highly contentious divorce – is strongly allied with Problems as “persistent and dysfunctional patterns of feel- one of the parents and persistently refuses the rela- ings, behaviours, and perceptions involving two or more tionship with the other alienated parent without any partners in an important personal relationship”, laying reasonable justification. The child refuses to visit the stress on the individual in the relationship. In order to be alienated parent and his/her custodial relationship. diagnosed, the relational disorder requires a pathological B. The child experiences the following behaviours: interaction between the actors involved in the relation- 1. persistent rejection or denigration of a parent that ship. DSM-5 classifies the parent-child relational prob- reaches the level of a campaign of denigration; lems among Relational Disorders. This category should 2. weak, superficial and absurd rationalisations for be used when the main object of clinical attention is the persistent criticism towards the rejected parent; quality of the relationship existing between parent and C. The child shows two of the six following attitudes and child, or when the quality of the parent-child relationship behaviours: dramatically influences the course, prognosis or treat- 1. lack of ambivalence; ment of a mental or a medical disorder. Parent-child rela- 2. phenomenon of the independent thinker; tional problems are associated with impairment in social, 3. automatic support of one parent against the other; behavioural, cognitive and emotional functioning. 4. absence of guilt towards the rejected parent; Cognitive problems, in particular, may include “negative 5. presence of borrowed scenarios; attributions of the other’s intentions, hostility toward or 6. extension of hostility to the extended family of the scapegoating of the other, and unwarranted feelings of rejected parent. estrangement”. The word alienation appears instead of D. The duration of the disturbance is at least 2 months. estrangement in the Italian translation of DSM-5. Howev- E. The disturbance causes clinically significant distress 13 er, in English the two words are considered synonyms . or impairment in social, academic, occupational, or Bernet 5 6 was one of the leading promoters of the inclu- other important areas. sion of parental disorder in the DSM-5. He argued 20 rea- F. The child refuses to visit the rejected parent without a sons for including it, stating that parental alienation is a reasonable justification. The parental alienation disor- valid concept, has been present in the literature for a long der is not diagnosed if the rejected parent abuses the time, may be conceptualised as an attachment disorder child. and defined by dimensional characteristics in line with the entire structure of the new Diagnostic Manual for Mental Disorders. Despite controversies on the terminol- Current debate on parental alienation ogy and aetiology, the phenomenon is almost universally and its diagnosis recognised by mental health professionals from different Despite a growing literature, the term parental alienation countries who assess and treat children involved in highly syndrome (PAS) continues to raise controversy in child conflictual divorces. The diagnostic criteria proposed for custody matters. Controversy exists, however, in concep- PAS are reliable. Systematic research indicates that the tualising the problem of alienated children and in us- diagnostic criteria can be considered reliable both on the ing the term PAS 14-17. Those favouring the term believe basis of test-retest reliability and internal consistency and it helps in understanding and treating a well-recognised it is possible to estimate the spread of parental alienation. phenomenon. Those opposing the term believe that it Systematic research indicates that in the United States lacks an adequate scientific foundation to be considered 1% of children and adolescents suffer from parental al- a syndrome and that courts should not admit testimony ienation, which is a serious mental condition. Its course often continues in adulthood and can cause serious prob- on PAS. Critics argue that PAS is either an unnecessary lems over time. Bernet also stressed the urgent need to or potentially damaging label for normal divorce-relat- establish adequate diagnostic criteria that can be helpful ed behaviour, that it oversimplifies the aetiology of the to clinicians working with divorced families and sepa- symptoms it subsumes, and that it may result in custody rated parents who are trying to do what is best for their decisions which fail to promote children’s welfare. children, in order to reduce the possibility for molesting parents and unethical lawyers to misuse the concept of Is there scientific evidence? parental alienation in disputes over children. Many authors criticise the existence of PAS, claiming In his proposal to include PAD in DSM-5, Bernet (2008) that clinical and empirical evidence is rather limited and purported the eight diagnostic symptoms already de- therefore there is not adequate scientific evidence. Actu- scribed by Gardner (1992), without the inclusion of the ally, careful research in the literature on the subject of other four symptoms Gardner later proposed (1998): parental alienation has shown that there are more than

234 Parental alienation syndrome or alienating parental relational behaviour disorder: a critical overview

500 studies on parental alienation 5, including several in Clinical and epidemiological research has shown that a Italy 18-22. high incidence of traumatic experiences during infancy and childhood has an impact on the subsequent devel- Is there gender imbalance? opment of the person 26. The psychopathological circuit Many PAS critics stressed that gender imbalance was pre- generated by trauma begins when a highly stressful event sent and that this was used by abusive fathers to discredit interacts maladaptively with the individual’s coping strat- women who requested protection for traumatised chil- egies: if these are inefficient, the traumatic event and dren. Recent studies have shown that the alienating par- its memory cannot be integrated and become dystonic. ents may be equally mothers or fathers. Initially, Gardner Among the factors that reduce coping ability there can indicated the mother as the alienating parent in 75-95% be an excessive malleability of the subject, as happens in of the cases; this statement has later been revised and children: they are not resilient, but malleable. Risk factors researchers have recently confirmed the fact that there is concern all the existential conditions of the child and his/ no gender prevalence 16 17. her environment that involve a higher risk of developing Baker and Darnall found that there were no differences a psychopathology than what is observed in the general between the gender of the targeted parent and gender of population; “minor” traumatic events or life stress events, the child, meaning that both mothers and fathers were and all their variables, interacting with each other, may alienating parents and both sons and daughters were tar- they be biological, temperamental, family and/or social gets of alienation. However, the gender and the age of variables that can be reinforced through cumulative ef- the targeted child were associated with the severity of fects. They consequently determine a higher psychopath- alienation. ological risk if compared to what can be observed in the general population. Clearly, vulnerability to life events is Is it possible to talk about syndrome? extremely variable, so it is reasonable to assume that the different circumstances which affect individual lives can The various criticisms addressed to the concept of PAS determine a mental disorder only if they act on a par- agree in considering scientifically unfounded the refer- ticular organisation of the person 27 28. A multiplicity of ence to a “syndrome” as a constellation of symptoms that clinical expressions connected to a history of childhood characterise the discomfort of a contended child 23. The trauma have been described including major depressive problem whether or not there is a “syndrome” related to disorder 29 34, dissociative disorders 30, or borderline per- the alienation of a parental figure is posed in an inade- sonality disorder 31. Given the same type of trauma at dif- quate way. PAS seems to be better defined as a “Disorder ferent ages, in childhood it causes alterations in differ- of Relational Behaviour”, not as a syndrome. Phenom- ent areas of the brain and different neuroendocrine sys- ena such as bullying, stalking and cruelty exist and have tems 32 33. Considering the short- and long-term negative legal significance regardless of recognition of disorders effects of trauma on individuals, the identification of the that can be identified as symptomatic. For example, sex- risk factors such as parental alienation is important for ual abuse exists even if there is not a “syndrome of the 22-24 both prevention and treatment of related disorders. abused child” . Bernet et al., 2015, retrospectively analysed the alienating behaviour present in an sample of Italian children and Is PAS a risk factor? described the psychosocial symptoms associated with Another criticism towards the definition of PAS is that them. An anonymous and confidential survey about their not only is there no mention of a possible suffering of childhood exposure to parental alienating behaviour and the child, but also there is no specification of the psychic measures of current symptomatology was completed by function that would be altered; the only aspect mentioned s739 adults in Chieti, Italy. About 75% of the sample re- is this “campaign of denigration” (essentially the refusal ported some exposure to parental alienating behaviour; expressed by the child of a relationship with one of the 15% of the sample endorsed the item, “tried to turn me parents) that, again, does not account for subjective suf- against the other parent.” The results showed strong and fering of the minor. PAS is the first illness in the world for statistically significant associations between reported ex- which a diagnosis is made without subjective suffering. posure to parental alienating behaviour and reports of PAS and conflictual separations represent for the child in- current symptomatology 34. volved an evolutionary risk condition that, however, does not determine itself and especially not in the short term, a psychopathological condition. Data in literature and clini- The alienating parental relational behaviour disorder (APRBD): our new concept cal practice highlight that parental alienation needs to be considered as psychological trauma and therefore an im- Based on the research carried out, we can state that portant risk factor for the onset of psychiatric disorders 22 25. parent alienation does not correspond to a “syndrome”

235 A. Siracusano et al.

or a specific individual psychic “disorder”. It can bet- It is not caused only by a pathological frame of one of the ter be defined as a dysfunctional family relation model subjects. A more correct definition of this disorder would determined by the excluding or “alienating” parent, be as follows: unmotivated activation by one parent (al- the excluded or “alienated” parent and the child, each ienating) of a campaign of denigration against the other member of this triad with his/her own responsibilities parent (alienated) which results in the child tenacious and contribution. It would, therefore, be more correct to and unmotivated refusal of the alienated parent, with or define the old concepts of PAS and PAD as an “Alienat- without alliance with the alienating parent, with or with- ing Parental Relational Behaviour Disorder” (APRBD). out a reasonable motivation to determine the campaign Different clinical features can then be defined, depend- of denigration. ing on the presence or absence of an effective alliance The psychopathological frame can be determined by var- with the alienating parent (Alienating Relational Behav- ious risk factors and various mediation factors: iour Disorder with parental alliance; Alienating Paren- • developmental phase; tal Behaviour Disorder without parental alliance) or the • family variables (e.g. presence of brothers, extended presence or absence of a motivation that underlies such family); dysfunctional behaviour (Alienating Parental Relational • intellectual level; Behaviour Disorder with motivation; Alienating Parental • style of attachment; Relational Behaviour without motivation) (Fig. 2). • coping strategies; The DSM-5 defines relational problems as “persistent and • resilience and malleability abilities. dysfunctional patterns of feelings, behaviour and percep- A child that presents with these risk factors might then tions involving two or more partners in an important per- experience the separation of their parents as a psycho- sonal relationship”. To be diagnosed as such, a relational logical trauma (life stress event) that results in the on- disorder requires the existence of a pathological interac- set of the “Alienating Relational Behaviour Disorder” tion between the individuals involved in the relationship. (Fig. 3).

Figure 2. PAS/PAD: an Alienating Parental Relational Behaviour Disorder? PAS/PAD: un disturbo del comportamento relazionale genitoriale di tipo alienante?

236 Parental alienation syndrome or alienating parental relational behaviour disorder: a critical overview

Figure 3. Alienating Parental Relational Behaviour Disorder (APRBD). Disturbo del comportamento relazionale genitoriale di tipo alienante.

In adulthood, the same child might develop narcissistic A nationwide systematic research is necessary to avoid personality disorders, manipulative and egocentric be- the misuse of this term and to consent to proper use of the haviour, sexual dysfunctions, or eating disorders. concept in clinical and forensic areas.

Conflict of interests Conclusions and future perspectives None. The explanation of this disorder has its own validity, but thorough research to clarify its features (e.g. duration and References intensity of symptoms) needs to be carried out, otherwise 1 ISTAT. Separazioni e divorzi in Italia - 23 giugno 2014. it could be instrumentally used in litigations. Further sys- 2 Lavadera AL, Ferracuti S, Togliatti MM. Parental Alienation tematic and large-scale studies of parental alienation are Syndrome in Italian legal judgments: an exploratory study. needed that take into account the issues discussed, and Int J Law Psychiatry 2012;35:334-42. proper objective diagnostic criteria should be defined for 3 Gardner, RA. Recent trends in divorce and custody litiga- scrupulous diagnosis and valid treatment. tion. In: The Academy Forum, 29,2, 3–7. New York: The With adequate scientific evidence about diagnosis, ther- American Academy of Psychoanalysis 1985. apy and prognosis, and the possibility of using appropri- 4 Gardner R. The parental alienation syndrome: a guide for ate assessment tools, the alienating parents and unethi- mental health and legal professionals. Cresskill, NJ: Creative cal lawyers would have fewer possibilities to misuse the Therapeutics, Inc 1998. concept of parental alienation in disputes over children. 5 Bernet W, Baker AJ. Parental alienation, DSM-5, and ICD-11:

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response to critics. J Am Acad Psychiatry Law 2013;41:98-104 21 Pignotti MS. Parental alienation syndrome (PAS): unknown 6 Bernet W. Parental alienation disorder and DSM-5. Am J in medical settings,endemic in courts. Recenti ProgMed Fam Ther 2008;36:349-66. 2013;104:54-8. 7 Cavedon A, Magro T. Dalla separazione all’alienazione pa- 22 Camerini GB, Magro T, Sabatello U, et al. Parental alienation: rentale. Come giungere ad una valutazione peritale. Milano: clinical, nosographic, psychological and legal considerations Franco Angeli 2010. after DSM-5. Gior Neuropsich Età Evol 2014;34:39-48. 8 Gardner RA. The parental alienation syndrome and the dif- 23 Mazzeo A. Sindrome di alienazione genitoriale (PAS): il ferentiation between fabricated and genuine child sexual grande imbroglio (Ebook). abuse. Cresskill, NJ: Creative Therapeutics 1987. 24 Di Blasio P. Dibattito sulla validità e affidabilità scientifica 9 Gardner RA. The parental alienation syndrome: a guide for mental health and legal professionals. Cresskill, NJ: Creative della Sindrome da Alienazione Parentale (PAS). Psicologia Therapeutics 1992. clinica dello sviluppo 2013;2:315-6. 25 10 Gardner RA. Should courts order PAS children to visit/reside Ariatti R, Cabras C, Camerini GB et al. Documentazione with the alienationparent? A follow-up study. Am J Forensic psicoforense sull’alienazione genitoriale - 15 ottobre 2012. Psychol 2001;19:61-106. 26 Widom CS, DuMont K, Czaja SJ. A prospective investiga- 11 Gardner, R. A. The judiciary’s role in the aetiology, symptom tion of major depressive disorder and comorbidity in abused development, andtreatment of the parental alienation syn- and neglected children grown up. Arch Gen Psychiatry drome (PAS). Am J Forensic Psychol 2003; 21: 39–64. 2007;64:49-56. 12 Fidler B, Bala, N. Children resisting postseparation contact 27 Niolu C, Barone Y, Bianciardi E et al. Resilienza e pathways di with a parent: concepts, controversies, and conundrums. sviluppo psicopatologico: diverse tipologie di trauma. Family Court Review 2010;48:10-47. Nóos 2015;21:25-34. 13 American Psychiatric Association. Manuale diagnostico e 28 Di Lorenzo G, Lisi G, Niolu C. Update sul trattamento dei statistico dei disturbi mentali, DSM-5. Milano: Cortina Raf- faello 2014. disturbi trauma correlati. Nóos 2015;21:51-69. 29 14 Gardner RA. Parental alienation syndrome vs parental al- Niolu C, Lisi G, Siracusano A. I disturbi dissociativi. In: Ma- ienation: which diagnosis should evaluators use in child- nuale di Psichiatria. Roma: Il Pensiero Scientifico Editore custody disputes? Am J Fam Ther 2002;30:93-115. 2014, pp. 463-85. 15 Gardner RA. Commentary on Kelly and Johnston’s “The 30 Siracusano A, Barone Y, Niolu C. La depressione. In: Manua- alienated child: a reformulation of parental alienation syn- le di Psichiatria. Roma: Il Pensiero Scientifico Editore 2014, drome”. Family Court Review 2004;42:61-106. pp. 305-49. 16 Baker AJL. Parental alienation: a special case of parental re- 31 Teicher MH, Samson JA, Polcari A et al. Length of time be- jection. Parental Acceptance 2010;4:4-5. tween onset of childhood sexual abuse and emergence of 17 Baker AJL. Adult recall of parental alienation in a com- depression in a young adult sample: a retrospective clinical munity sample: prevalence and associations with psycho- report. J Clin Psychiatry 2009;70:684-91. logical maltreatment. Journal of Divorce & Remarriage 32 Wingenfeld K, Spitzer C, Rullkötter N et al. Borderline per- 2010;51:16-35. sonality disorder: hypothalamus pituitary adrenal axis and 18 Buzzi I. La sindrome di alienazione genitoriale. In: Cigoli V, findings from neuroimaging studies. Psychoneuroendocri- Gulotta G, Santi G, a cura di. Separazione, divorzio e affida- nology 2010;35:154-70. mento dei figli. II ed. Milano: Giuffré 1997, pp. 177-88. 33 Andersen SL, Teicher MH. Stress, sensitive periods and mat- 19 Gullotta G, Buzzi I. La sindrome di alienazione genitoriale: definizione e descrizione. Pianeta infanzia, Questioni e do- urational events in adolescent depression. Trends Neurosci cumenti, n. 4. Istituto degli Innocenti di Firenze, 1998. 2008;31:183-91. 20 Giorgi R. Le possibili insidie delle Child Custody Disputes: 34 Bernet W, Baker AJ, Verrocchio MC. Symptom Checklist- introduzione critica alla sindrome di alienazione parentale 90-Revised scores in adult children exposed to alienating be- di Richard Gardner. Febbraio 2005. haviours: an Italian sample. J Forensic Sci 2015;60:357-62.

238 Original article

E. Rosini, D. Pucci, G. Calabrò, P. Girardi Dipartimento NESMOS Facoltà di “Medicina e Psicologia”, Sapienza Università di Roma, Italia

Summary alence of hospitalised patients [including those already under An overview is provided of the characteristics and critical as- care (generally for recurrent acute psychotic and mood disor- pects of a psychiatric community model that forms the basis for ders) and those experiencing first contact with psychiatric ser- psychiatric assistance in Italy. In particular, the MISM (Modulo vices] increased in recent years, because of the second ones, Integrato Sperimentale per la Salute Mentale; integrated experi- with shorter hospitalisation times. mental module for mental health) project in the Lazio region is described, which integrates assistance, research, training and Objectives teaching between a psychiatric clinic and a community health The aim of this study is to describe the psychiatric health care unit in Rome inspired by the guidelines of the World Psychia- management of a territorial catchment area through the partner- try Association Action Plan (2008-2011). The indicators of suc- ship between a University Hospital agency for acute patients cess of the project (reduction in total number of hospitalisations together with public psychiatric network agencies, sharing com- in the catchment area) required by the Lazio region were fully mon clinical guidelines. achieved. In addition, the overall efficacy and efficiency of the The goal of the research is to evaluate quality of this partnership assistance offered, along with the pilot experience of the partner- through a specific goal, consisting in assessing the amount of ship between the university and local health services considering hospitalizations per year, from 2010 onward, confronting these training, research activities and teaching, were obtained without results with those of preceding years. an increase in regional healthcare expenses and in accordance with local regulations. The number and types of hospitalisations Key words over time were compared before and after the implementation Community psychiatry • Outpatient center • School of medicine • of the MISM in May 2010. From a clinical standpoint, the prev- Catchment area

Introduction emergency service and residential facilities for long-term patients. The clinical model, a public health one, is char- Psychiatric assistance in Italy is based on a community acterised by continuity of care – both longitudinal conti- 1 model . Community mental healthcare is founded on nuity (through the different phases of treatment) and cross- deinstitutionalisation; the need to reduce the level of de- sectional continuity (through the different components of pendence on assistance required; better utilisation of non- the service) 4. professional resources; greater level of patient participa- A particularly important aspect of the system in Verona is 2 tion in decision-making processes . In Italy, over time, “the single staff model”, where each patient is assigned there has been sporadic reorganisation of psychiatric to a particular psychiatric team and is followed by a services, one example of which is the experience of the member of the staff (the “case manager”). Case managers South Verona Community Mental Health Service 3. The may be doctors, psychologists or senior nurses. All staff South Verona CMHS, provides a comprehensive and well- work both inside and outside the hospital setting, and integrated spectrum of services to a population of about retain responsibility for the same patients across differ- 100,000 inhabitants who live within a defined geographi- ent components of the service and through all phases of cal area in the south of Verona. These services include: treatment. This system was designed to ensure continuity in-patient, day patient and out-patient care, rehabilita- of care, both longitudinal continuity and cross-sectional tion, community care (including home visits), a 24-hour continuity.

Correspondence Enrico Rosini Dipartimento NESMOS U.O.C. Psichiatria Ospedale Sant’Andrea, via di Grottarossa 1035-9, 00189 Roma, Italia • Tel. +39 06 33775668 • Fax 06 33775399 • E-mail: enrico.rosini@ uniroma1.it

Journal of Psychopathology 2015;21:239-245 239 E. Rosini et al.

While respecting the basic assumptions of community ficacy, and those based on evidence rather than political care, which direct the organisation of services, some of requisites should be privileged. This prospect is still not these changes have been maintained 5 6. possible in Italy, which has given less attention to plan- The goal of local mental health services, as reinforced by ning and establishing goals, with the creation of services national objectives defined during 1998-2000, consists in oriented only towards ‘needs’ 15. Another negative conse- understanding the needs of and caring for patients with quence is the lack of attention given to user participation severe mental health issues. This priority thus defines the in treatment choices and in reducing their dependency major aims and justifies several basic premises: their pub- on services, and not considering the patient as a valid lic nature (not necessarily to provide service but to take participant in the therapeutic partnership 16 17. responsibility); deliver services to the entire territory; the In some European countries, the emergence of new so- organisational model adopted (such as the facilities used cial and youth problems and increased demand has been and standards of care); a multidisciplinary approach and met with greater determination than in Italy, where the centralisation of the management team; a proactive ap- percentage of spending on mental health has reached 9% proach to care that neither questions nor refuses treat- of healthcare resources 18 19. ment; development of high-risk, targeted interventions Franco Basaglia believed that scientific research carried (e.g. in prison settings); the assumption of active protec- out in a university setting could produce knowledge that tion against highly impaired clients (which are complex is separate from the harsh reality of a psychiatric hospital, from both technical and ethical viewpoints); the exten- and assumed that academic and scientific research had sion of intervention to social insertion of severely com- little connection with practical issues. The professional- promised patients in employment and support networks; ism advocated by Dr. Basaglia was more pragmatic than defend against social stigma; involve family members in scientific. Indeed, the Italian law on deinstitutionalisa- treatment as an essential component of care in intervention and psychiatric reform (Law 180) makes no mention tions aimed at overcoming social isolation 7 8. of the role of the university and psychiatric clinics, and Such a guiding philosophy is becoming increasingly limited their activity to voluntary admissions within the widespread in economically advanced countries 9, but framework of the National Health System. it still unclear how this is being applied in Italy. In this In fact, Law 180 abolishes hospital psychiatric clinics, regard, the process initiated in the 1980s (1978) appears and limits their objectives to training and teaching within to have slowed down, with the risk that this may lead to the university. Due to this law, which no longer allowed marginalisation within the international psychiatric com- university-based psychiatric assistance, universities were munity 10. forced for decades to train healthcare professionals in The reasons behind such anomalies in Italy also involve hospitals and ambulatory clinics independently of the a reduction in economic resources over the last decade university, and participated in daily clinical activities that (from 2000 to 2007 per capita health expenditure grew had little to do with training, teaching or research. Only less than the OECD average). Moreover, some of the most recently have universities become reinserted in patient resistant obstacles to change include: residual ideologies, management with the opening of clinics in community not necessarily political, which even if well-intentioned, hospitals, even if their overall contribution is still modest have created a hierarchy in which individual profession- and only a small proportion of university psychiatric clin- als govern clinical processes; a progressive lack of inter- ics are directly involved in management of community est in scientific publications that can provide guidance metal health. for patient management, except for the use of diagnostic On the other hand, management, which relies on costly categories from recognised classification systems 11. organisation of complex healthcare resources such as In this regard, and considering the increasing need for those in community psychiatric services, should concen- ‘accountability’ 12, it would appear that greater focus trate on selected key parameters: objective evaluation of should be placed on the quality of intervention (including efficacy and efficiency of care, health status of clients, user satisfaction and quality perceived by family mem- quality and efficiency of therapeutic processes, innova- bers) 13, overall expenses and competitiveness between tion and development of the skills needed to overcome care facilities. Ideally, this could lead to closure of less potentially negative processes where operators tend to efficient facilities 14 and redistribution of resources. It is assume neutral roles in order to become interchangeable also necessary to review the organisation of services, operators that can ‘do everything’ 20-22. where each facility is autonomous and free of specific As reiterated in the National Project Objective (1998- geographic constraints, and able to function without con- 2000), the mission of psychiatric services is to take care sidering other facilities within the same territory. On the of individuals affected with severe mental health disor- basis of this hypothesis, community psychiatric services ders. The largest proportion of human and economic re- should be accurately evaluated on the basis of proven ef- sources are utilised in the treatment of severe psychiatric

240 MISM: Clinical and epidemiological data of a new Italian Public Mental Health Care Model in development

disorders in adults, although it is increasingly evident that • Ambulatory Facility (C.D.), via Pasquariello, 4; emerging disorders are also having substantial impact: re- • Sant’Andrea Hospital Psychiatry Department (Sapi- current episodes in adolescents and young adults, over enza University of Rome). time, can lead to severe psychotic disorders; personality Interns at the Department of Psychiatry divided their time disorders; dual diagnoses; eating disorders; comorbidi- between the hospital and satellite facilities, consisting of: ties with somatic disorders or in older individuals; youth regular shifts, following patients and tutoring by senior unrest. Such disorders have the potential to become epi- psychiatrists; regular emergency department shifts; home demic, with subthreshold aspects that can lead to their visits; individual and group psychotherapy (recent tech- underestimation 23. niques introduced by the regional mental health care Over the last 15 years, two mental health projects have centre) 25; participation in regular organisational and been undertaken that have contributed to the develop- training meetings. ment and organisation of current mental health services, Starting November 2012, weekly multifamily group even though the role of the university has been minimal. psychotherapy sessions were held in the ward, that in- In reality, universities have been largely excluded from volved healthcare operators, in-patients and families and projects aimed at reforming psychiatric services in Italy. at outpatient facilities at later dates: preliminary reports University psychiatry, which is responsible for training show an increased compliance to treatment, in the next over 95% of psychiatric healthcare personnel, must have six months from dehospitalisation, for those patients and an increasing role in hospitals and in territorial services. their families involved. At the same time, in specialised training centres, 30-60% The in-hospital management schemes and collaboration of teaching is carried out by those involved in local psy- between caregivers tended to follow the overall charac- chiatric services. The university now has the opportunity teristics of the multidisciplinary team at local facilities 26. to play a more active role in training healthcare operators Moreover, the degree programme for technicians in psychi- and to be a driving force between the evolution of sci- atric rehabilitation at Sant’Andrea hospital, which is a joint entific psychiatry and economic-organizational services collaboration with the university and Mental Health Care, with the framework of public assistance. allowed for mobility of personnel during training 27 28 29.

Organisation of the m.i.s.m. project Statistical analysis The present study describes the clinico-epidemiological Descriptive statistics were used in studying the catchment results, the organisational aspects and the specific objec- area data, with quantifiable data expressed as mean ± tives, established Lazio Region, of the MISM pilot project standard deviation, and socio-demographic and clinic (Modulo Integrato Sperimentale per la Salute Mentale; factors as frequency and percentage. Statistical analyses integrated model for mental health), based on a partner- were performed using the Chi square (χ2) and Kruskal- ship between the university and community psychiatric Wallis test. services in terms of client assistance and a network of local hospital and territorial facilities. We have tried to Results adopt the guidelines of the WPA Action Plan 2008-2011, Community Mental Health Care 24. Figure 1 shows the number of hospitalisations from 2008 The protection of mental health in a defined geograph- to 2014: total number of hospitalisations, total number of ic area was thus entrusted to a Department of Mental hospitalisations in the catchment area and number of ‘first’ Health in which a University Psychiatric Clinic has been hospitalisations at the Department of Mental Health. As inserted. can be seen, there is an increase in the number of hospi- The MISM began its activities in May 2010 based on talisations from 2010 onwards when MISM was instituted. decrees from the Lazio region, and a protocol was Figure 2 shows the trend of the number of hospitalisa- agreed the Department of Mental Health, university and tions since 2008 to 2014. It shows the total amount of Sant’Andrea Hospital regarding exchange of personnel. hospitalisations, the total number of in-patients, the num- The objectives of MISM, established as ‘indicators’ by the ber of previously-hospitalised (known patients) and first Lazio region, were reduction in admittances to the emer- hospitalisations patients (unknown patients) at the Mental gency department and hospitalisations in the geographic Health Centre. It can be seen that the number of hos- areas covered by the project. The catchment area, facili- pitalisations of already-known patients decreased after ties and operators primarily affected by MISM include: implementation of the MISM, while those for first hospi- • Regional healthcare system ASL RMA IV (population talisations increased. There was a statistically significant 130,000); difference between the two groups, known vs. unknown • Mental Health Centre (C.S.M.), via Lablache, 4; patients (p < 0.001).

241 E. Rosini et al.

Figure 1. Hospitalisations during the period from 2008 to 2014. Ricoverati totali in S.P.D.C. dal 2008 al 2014.

Figure 2. 2008-2014 trend of hospitalisations. Chi square test between known vs unknown patients (p < 0.001; χ2 = 30.61; 6 d.f.). Andamento delle tipologie di ricovero dal 2008 al 2014.

242 MISM: Clinical and epidemiological data of a new Italian Public Mental Health Care Model in development

Table I. Clinical and epidemiological characteristics of first hospitalisations during 2012-2014. Details first hospitalisations over the last three years. Caratteristiche clinico-epidemiologiche dei ricoveri di pazienti sconosciuti ai Servizi dal 2012 al 2014.

Year Patients Mean Mean Mean age Reactions Psychoses Affective Non-voluntary Non- Substance age* age females† % % disorders hospitalisation Italian abuse % (±SD) males§ (±SD) % % % (±SD) 2012 26 39,5 42,1 38,4 23 38 39 46 23 18 (±15.2) (±16.1) (±15.1) 2013 27 40,3 36,0 47,7 41 22 37 22 26 33 (±13.8) (±12.7) (±12.9) 2014 27 39,7 36,4 43,2 22 44 33 41 19 30 (±13.5) (±9.7) (±16.3) * § † Kruskal-Wallis test (p > 0.05).

Discussion the expression of a phenomenon of diffuse social and economic malaise as some clients may no longer be able The MISM project was initiated in May 2010. During the to afford private care, in contrast with past years. first 6 months of this innovative network of psychiatric These patients, previously unknown to psychiatric ser- facilities, a decrease in the number of hospitalisations by vices, had a higher mean age than analogous patients in about 15% at the Department of Mental Health was ob- previous years (Table II). Thus, these are not young patients served in the catchment area over the previous reference with a first symptomatic psychotic episode, but older pa- year. Figure 1 shows the number of in-patient recover- tients with prevailing affective symptoms. In 2012, 11 of ies at Sant’Andrea hospital from 2008 to 2014: the total these hospitalisations, or 46% of the first 26 hospitalisa- number of yearly hospitalisations can be compared for tions, were non-voluntary. Moreover, non-voluntary hospi- known and previously-unknown patients, both from the talisations were distributed homogeneously in terms of age catchment area. Considering this, there was a decrease (an index of severity of symptoms and independent of age). in the number of overall hospitalisations after the project Thus, these recoveries did not involve only young patients was initiated, from 108 in 2008 (29% of total), to 72 in with a first symptomatic episode and poor compliance to 2014 (18% of total). therapy, as was generally observed in previous years. During 2012, an increase (n = 90) in the total number During 2013, and confirmed in 2014, a slight increase of hospitalisations was observed in the catchment area was observed in the number of first hospitalisations as compared to 2011 (n = 76), although there was a deep seen in Figure 2. In addition, there was an increase in increase in hospitalisation for first episodes (26 in 2012 the frequency of substance abuse, largely cannabinoids, and 10 in 2011). These were generally attributed to acute and an increase in the proportion of males hospitalised, psychotic episodes in young patients, and recurrent epi- with a mean age that was greater than that of hospitalised sodes in middle-age patients: thus these were individuals females; the proportion of non-Italian patients remained who had not been in previous contact with psychiatric unchanged. The changes in diagnostic categories ob- services, or who had had first contact within two weeks served, along with the percentage of non-voluntary hos- prior to hospitalisation. The tendency towards a net in- pitalisations compared to the previous year, are worthy crease in previously-unknown patients was also seen in of note. In 2013, the mean length of hospital stay for pa- 2013 and confirmed in 2014, although a decrease in total tients with first hospitalisations was 7.8, while it was 12.9 hospitalisations was also observed. The large number of days for those who had been hospitalised before 2013. hospitalisations compared to the previous year could be During 2013, the presence of significant symptomatology, attributed to a shift in economic resources in Rome and even if of uncertain diagnosis upon admission, was some- surrounding areas in which some facilities were closed times referred to as “Brief Reactive Psychosis”, nonetheless due to structural reorganisation, with a corresponding in- required hospitalisation and demonstrates that there was a crease in the patient load at Sant’Andrea hospital. reactive component at the basis of the disorder. There was, therefore, an increase in hospitalisations for In our patient cohort, we often observed manifestations first episodes during the last years. On one hand, this can of life events that were frequently related to the economic be attributed to the ability of psychiatric services to meet crisis, especially in low income families, where there was increased demands, while on the other it also represents a deterioration of relationships both within families and

243 E. Rosini et al.

Table II. Socio-demographic and clinical characteristics of patients in the catchment area. Summarises the socio-demographic and clinical characteristics of patients in the Catchment Area from 2008 to 2014. Caratteristiche cliniche e socio-demografiche dei pazienti provenienti dalla Catchment Area dal 2008 al 2014.

Year Total Hospitalisations Hospitalisations Patients Non-voluntary Mean age hospitalisations in catchment in catchment with first admissions with at first area area hospitalisation first hospitalisation hospitalisation (N) (%) (%) (%) (±SD) 2008 387 108 (90) 28% 15 (14%) 9 (60%) 25,3 (±3.5) 2009 376 95 (81) 25% 10 (11%) 6 (60%) 27,2 (±5.3) 2010 337 72 (60) 21% 12 (17%) 4 (33%) 27,6 (±7.4) May MISM 2011 412 76 (62) 18% 10 (13%) 5 (50%) 28,3 (±7.5) 2012 392 90 (76) 22% 26 (34%) 11 (46%) 38,3 (±14.1) 2013 447 86 (76) 19% 27 (35%) 4 (22%) 40,4 (±13.2) 2014 403 72 (66) 18% 27 (56%) 15 (56%) 39,7 (±13.5) social surroundings, involving Italians as well as the out- If one considers that characteristics of the study population sized immigrant population. in the catchment area (Table I), it can be seen that in 2013 Moreover, it was apparent that there is widespread sub- there was an increase in the mean age of female patients, stance abuse due to the easy availability of illegal drugs 30. while that of males remained stable compared to 2012, with Even if there is a recognisable cause, intervention is not a consequent slight decrease in female mean age in 2014. made easier, given that it requires economic, pharmacologi- In recent years, the ‘revolving door’ problem has been cal and psychotherapeutic interventions that are rendered somewhat reduced, even if numerically very limited, difficult by the lack of trained personnel and resources. through better integration between various facilities and In Figure 2 an interesting trend can be observed over time insertion of patients in community therapies. between the proportion of known patients and those with Figure 3 summarises the diagnostic categories at dis- first recovery. During the present project, a decrease in charge in the catchment area during the period of study. hospitalisations of previously-known patients was noted, The high percentage of ‘other’ is related to the increase which can be interpreted as an indicator of the quality of seen in recent years of dual diagnoses, comorbid symp- service provided. This is in consideration that there was tomatology and personality disorders. Schizophrenic dis- less need for in-patient hospitalisation among those fol- turbances are more frequent than mood disorders, which lowed by Community Mental Health Services, generally confirms observations in previous time periods. involving chronic schizophrenic and affective disorders. Figure 2 shows the number of hospitalisations of patients Conclusions who were already known to psychiatric services, which relative to previous years before the institution of the 1) In our opinion, for decades there has been outdated MISM, was around 50 per year. This would seem reason- management of Mental Health Departments that has cre- able based on the population base of 130,000. It is pos- ated intractable fractures in satellite and hospital services, sible to believe that this number could be further reduced, with little communication, which has led to deficits in as it happened in 2014, if additional resources were avail- knowledge and the quality of care. Such a situation is unable. It is, nonetheless, a valid indicator of the authenticity doubtedly far removed from a clinical approach based on and quality of the project in that it describes stable but efficacy and accountability, and can bring about recipro- improved efficiency of the organisation of care provided. cal distrust and tensions among healthcare operators. It is Table II details the characteristics of the population in the our belief that our study favoured integration between the catchment area over time, including the number of overall university and the Department of Mental Health, as well first hospitalisations and proportion of non-voluntary in- as innovative organisation and guidelines, which led to patient recoveries. In the most recent years, this was about benefits in terms of therapeutic continuity. 20% of total hospitalisations, which is in agreement with 2) After about five years, many of the objectives of the decrease seen after the initiation of the MISM project. MISM have been achieved – at no additional cost –

244 MISM: Clinical and epidemiological data of a new Italian Public Mental Health Care Model in development

psichiatria di comunità. In: Ferranini L, ed. Politiche sanitarie in psichiatria. Milano: Masson 2003, p. 53. 8 Thornicroft G, Tansella M, Law A. Steps, challenges and lessons in developing community mental health care. World Psychiatry 2007;7:87-92. 9 Asioli F, Berardi D. Disturbi psichiatrici e cure primarie. Ro- ma: Il Pensiero scientifico 2007;72:96. 10 Grassi G. Priorità limiti e confini del DSM. Psichiatria di Co- munità 2007;6:28-36. 11 Scorza G. Il lavoro d’èquipe tra mito e realtà. Psichiatria di Comunità 2007;6:55-61. 12 Mistura S. Motivi di qualità in Psichiatria. In: Psichiatria e garanzia di qualità. Bologna Editrice compositori 2002. 13 Montemagni C, Birindelli N, Giugiario M, et al. Miglioramen- Figure 3. to clinico e soddisfazione del paziente come indici di qualità Overall percentage of diagnoses at discharge from 2010 to nel ricovero psichiatrico. Giorn Ital Psicopat 2012;18:40-8. 2014. Diagnosi alla dimissione dal 2010 al 2014. 14 Ducci G, a cura di. Buone pratiche in SPDC. Collana Psi- chiatria D’Urgenza. Roma: Aipes 2010, pp. 32-46. 15 Gabbard GO, Kay J. The fate of integrated treatment: what- and further provide evidence of its value. One impor- ever happened to the bio-psychological psychiatrist? Am J tant objective, in addition to respecting already Lazio Psychiatry 2001;15:1956-63. Region established indicators: reduction in the num- 16 Prince JD. Determinants of care satisfaction in inpatients ber of emergency admissions and hospitalisations in with schizophrenia. Comm Ment Health J 2006;42:189-96. the catchment area. These proportions would be even 17 Tatarelli R, De Pisa E, Girardi P. Curare col paziente. Roma: smaller if the increase in first recoveries over the last Il Pensiero Scientifico 1998. three years was not considered. 18 Dirigenza Medica 2007;3;12-15. 3) This positive data can be attributed to the development 19 Dirigenza Medica 2009;6:1-4. of a clear statement of the overall philosophy and tangi- 20 ble objectives of the project, which will be the subject Tibali G, Govers L. Evidence based hope. La proposta di una prospettiva comune. Psichiatria di Comunità 2009;5:117-129. of future efforts. This positive data can be attributed to a 21 greater presence of psychiatric services on a local level Munizza C, Donna G, Nieddu S. Finanziamento e management del Dipartimento di Salute Mentale. Bologna: Il Muli- and better coordination with the hospital, thereby rap- no 1999, pp. 119-60. idly meeting the needs of the entire population through 22 Colozzi I, a cura di. Sociologie e politiche sociali. Milano: better utilisation of available personnel. Franco Angeli 1998;2:6-69. 23 Mc Gorry P. Is the early intervention in the major psychiatric Conflict of interests disorders justified? Yes. Br Med J 2008;337:695-702. None. 24 Maj M. World Psychiatry Action Plan 2008-2011. World Psychiatry 2009;8:65. References 25 Badaracco JG, Narracci A. La psicoanalisi multifamiliare in 1 Ferranini L, Peloso PF. Il modello dipartimentale in psichia- Italia. Torino: Antigone 2011;17-31. tria. In: Ferranini L, ed. Politiche sanitarie in psichiatria. Mi- 26 Bassi M, Maurizzi A. Qualità e accreditamento nei DSM. lano: Masson 2003, pp. 31-8. In: Ferranini L, ed. Politiche sanitarie in psichiatria. Milano: 2 Maj M. Mistakes to avoid in the implementation of commu- Masson 2003;191-5. nity mental health care. World Psychiatry 2010;9:65-6. 27 Liberman RP. La riabilitazione psichiatrica. Raffaello Cortina 3 Thornicroft G & Tansella M. Per una migliore assistenza psi- 1997, pp. 37-49. chiatrica. Roma: CIC 2010, pp. 31-46. 28 Perone R, Bartolini L, Pecori D, et al. Risultati del Social 4 Thornicroft G, Tansella M. The Mental Health Matrix. A Skills training applicato a pazienti con sindromi psicotiche. Manual to Improve Services Health Matrix. Cambridge Uni- Giorn Ital Psicopat 2011;17:413-24. versity Press 1999. 29 Corrigan PW, Larson JE, Rusch N. Self stigma and the “why 5 Payne M. La costruzione dei piani assistenziali nelle cure di try” effect: impact on life goals and evidence-based prac- comunità. Erickson Trento 1998;27-32. tices. World Psychiatry 2009;8:75-81. 6 Priebe S, Slade M. Evidenze scientifiche per la Salute Men- 30 Rosini E, Calabrò G, Pucci D, et al. La doppia diagnosi nel tale. Il Pensiero Scientifico Roma 2003;13-37. SPDC: uno studio clinico trasversale. Dipendenze Patologi- 7 Ferranini L, Commodari E. Il DSM: modelli e strumenti della che 2013;1:15-20.

245 Original article

Metabolic syndrome in acute psychiatric inpatients: clinical correlates Sindrome metabolica in pazienti ricoverati in S.P.D.C.: correlati clinici

F. Solia, G. Rosso, G. Maina SCDU Psichiatria, AOU S Luigi Gonzaga di Orbassano, Dipartimento di Neuroscienze, Università di Torino, Italia

Summary Results One hundred twenty-five patients were enrolled. Of these, 37 Objectives (29.6%) had schizophrenia spectrum and other psychotic disor- Compared to the general population, patients with major men- ders, 47 (37.6%) had bipolar and related disorders, 28 (22.4%) tal disorders have a higher prevalence of metabolic syndrome had depressive disorders and 13 (10.4%) had personality dis- (MetS), which is known to increase cardiovascular risk and mor- orders. MetS was present in 35.2% of the sample. Low HDL-C levels tality. Many factors contribute to development and maintenance were the most frequently endorsed criterion, present in 57.6% of metabolic disturbances in psychiatric patients. Nevertheless, of subjects. Abdominal obesity, high triglycerides, hypertension gaps remain in relevant aspects, encouraging further studies in and fasting hyperglycaemia were observed in 51.2%, 30.4%, specific subgroups to evaluate the impact of each variable in 28.8% and 20% of patients, respectively. Patients who fulfilled developing MetS. Our aim is to identify the clinical and sociode- MetS definition were more often characterised by current atypical mographic features consistently associated with the occurrence antipsychotic treatment, current alcohol abuse, current psychiatric of MetS in a sample of inpatients affected by severe and acute comorbidity with substance related disorders and longer duration mental illness. of illness. After performing regression analysis, only current atypical antipsychotic treatment was significantly associated to MetS. Methods Our study had a naturalistic design and involved inpatients Conclusions consecutively admitted to the Psychiatric Unit of ‘S Luigi Our study confirms the increased risk of MetS in patients treated Gonzaga Hospital’ of Orbassano from December 2013 to with atypical antipsychotics. No other clinical or sociodemo- September 2014. At study entry, general sociodemograph- graphic variables were associated with MetS. These findings sug- ic and clinical information was collected for each subject, gest a shared susceptibility to antipsychotic-related metabolic including lifestyles and comorbidity for cardiovascular dis- dysregulation that is not primarily related to psychiatric diagnosis eases and diabetes. Through index visit and routine blood or concomitant to other psychiatric treatment. exam, all metabolic parameters were assessed to define the presence of MetS according to NCEP ATP III modified crite- Key words ria. Sociodemographic and clinical correlates of MetS were Metabolic syndrome • Atypical antipsychotics • Inpatients • Schizophre- then investigated. nia • Bipolar disorder

Introduction of CV risk, which is overrepresented in this population, is the cluster of findings that define metabolic syndrome Patients with major mental disorders are subject to pre- (MetS) 7-10. mature death from all causes compared to the general 1 More specifically, MetS occurs in nearly one-third of pa- population . Among causes of death, cardiovascular (CV) 11 12 disease is responsible for as much as 50% of excess mor- tients with schizophrenia , while 37.3% of patients tality. The association between CV risk and major mental with bipolar disorder develop MetS, which is nearly twice 13 14 disorders such as bipolar disorder and schizophrenia is the rate in the general population . well established and comparable 2-4. Furthermore, indi- Many factors contribute to development and maintenance viduals with unipolar major depression have levels of CV of MetS in psychiatric patients including poor lifestyle risk that are at least as high as those in patients who suffer choices, such as excessive caloric and cholesterol intake, from bipolar disorder 5 6. cigarette smoking and physical inactivity 15 16. Moreover, There are many reasons why patients with mood and psy- major psychiatric disorders have been related to genetic chotic disorders have elevated CV risk, but one source liability and lifelong use of medications such as antipsy-

Correspondence Giuseppe Maina, SCDU Psichiatria, AOU S Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano (TO), Italia • Tel. +39 011 9026974 • Fax 011 9026669 • E-mail: [email protected]

246 Journal of Psychopathology 2015;21:246-253 Metabolic syndrome in acute psychiatric inpatients: clinical correlates

chotics or mood stabilisers that have been associated with Assessments and procedures weight gain, dyslipidaemia and development of diabetes. At study entry, general sociodemographic and clinical in- Longitudinal follow-up studies to estimate changes in MetS formation was collected for each subject. Lifestyles were rates among patients with schizophrenia and bipolar disor- also investigated in the study sample: information about der suggest that the prevalence of MetS usually increases exposure to cigarette smoking, duration of alcohol and over time, in parallel with duration of illness and treat- drug consumption and physical activity was obtained by 17-19 ment . A recent study from our research group showed directly interviewing patients. A score was assigned to the that MetS rapidly increases from 28.6 to 44.3% over 2 years intensity of physical activity: absent, mild (< 4 h/week), follow-up in a sample of patients with bipolar disorder treat- moderate (4 h/week) and intense (> 4 h/week, regular) 23. ed as usual; moreover, patients developing MetS over time Comorbidity and family history for diabetes or cardiovas- were taking antipsychotics at baseline, most of which were cular diseases and current treatments for hypertension, atypical antipsychotics, confirming the increased risk asso- diabetes or dyslipidaemia were assessed by looking at 20 ciated with this class of medications . In addition to dura- medical reports and by directly interviewing patients. At tion of illness, gender should be another clinical parameter index visit, weight, height, waist circumference and blood that needs to be highlighted in evaluating the risk profile pressure were measured. Weight was measured with the of MetS. Few studies have reported higher rates of MetS in participant undressed and fasting height was measured males with bipolar disorder, with a prevalence of around barefoot. Waist circumference, measuring central adipos- 32% in men and 22% in women 21. On the other hand, a ity, was measured midway between the inferior margin of high prevalence of MetS was noted in women (52%) com- the ribs and the superior border of the iliac crest, at mini- pared to men (36%) with schizophrenia 8. mal respiration. Two blood pressure measurements were While considerable debate exists regarding the causes of obtained by using a mercury sphygmomanometer: the first the high prevalence of metabolic disturbances in patients with the subject in a supine position and the second with with severe mental illness, gaps remain in relevant as- the subject in a seated position at least 2 min after the first pects, encouraging further studies in specific subgroups measurement. The mean blood pressure of the two meas- of psychiatric patients to evaluate the impact of each urements was used. All the procedures were performed by variable in developing MetS. Our aim is to identify the the attending physician in the hospital setting. clinical and sociodemographic features consistently as- A blood draw for routine blood exam was performed sociated with the occurrence of MetS across different di- upon hospital admission, as part of routine clinical man- agnostic groups in a sample of patients affected by severe agement. At the time when blood was drawn, patients and acute mental illnesses. were fasting for the previous 10 h; patients who did not fast were rescheduled. Blood exams included assessment Materials and Methods of the following: glucose, total cholesterol, triglycerides, LDL and HDL-C. Patients were stated to have MetS if they The study had a naturalistic design and involved inpatients endorsed at least three of the following five criteria, ac- consecutively admitted to the Psychiatric Inpatient Unit of cording to NCEP ATP III modified criteria: the San Luigi Gonzaga Hospital, Orbassano (University of • abdominal obesity: waist circumference ≥ 102 cm in Turin, Italy) from December 2013 to September 2014. men and ≥ 88 cm in women; • hypertriglyceridaemia: ≥ 150 mg/dl or on being lipid- Subjects lowering medication; All patients consecutively admitted to the inpatient unit • low HDL-C: < 40 mg/dl in men and < 50 mg/dl in were considered for the present study. Patients with a women or being on triglyceride-lowering medication; main diagnosis of schizophrenia spectrum and other psy- • high blood pressure: systolic pressure ≥ 130 mmHg or chotic disorders, bipolar and related disorders, depres- diastolic pressure ≥ 85 mmHg or on antihypertensive sive disorders or personality disorders (DSM-5) 22 were medication; asked to participate. The aims of the study and study pro- • high fasting glucose: ≥ 100 mg/dl or being on glucose- cedures were thoroughly explained to potential partici- lowering medication. pants who gave oral consent before participation. Exclu- sion criteria included age < 18 years, severe and unstable Statistical analysis general medical conditions, any of the remaining main Characteristics of subjects were summarised as mean and psychiatric diagnoses (e.g. substance related disorders, S.D. for continuous variables and frequency and percent- neurodevelopmental disorders, neurocognitive disor- age for categorical variables. We examined sociodemo- ders), pregnancy or having just given birth and refusal to graphic and clinical correlates of MetS using a chi-square give consent prior to participating in the study. test in the case of categorical variables, performing the

247 F. Solia et al.

Yates correction in the case of a 2×2 table and independ- (±13.51) years; 48% of patients were females; 29.6% had ent-samples t tests in the case of continuous variables. In schizophrenia spectrum and other psychotic disorders, order to control for confounding factors, we entered the 37.6% had bipolar and related disorders, 22.4% had de- significant independent variables in a stepwise logistic pressive disorders and 10.4% had personality disorders. regression analysis (LogReg) with MetS as the dependent Sociodemographic and clinical characteristics are shown variable. in Table I. Of the 125 patients, MetS was present in 35.2% of the sample. Low HDL-C levels were the most frequently en- Results dorsed criterion, present in 57.6% of subjects. Abdominal One hundred twenty-five patients were recruited in the obesity was the second most frequent metabolic abnor- study. The mean (±S.D.) age of the sample was 44.94 mality, affecting 51.2% of participants. High triglycerides, hypertension and fasting hyperglycaemia were observed in 30.4%, 28.8% and 20% of the sample, respectively (Table II). Table I. We divided the sample in two groups according to the Baseline sociodemographic and clinical characteristics of presence (n = 44) or the absence (n = 81) of MetS crite- the sample. Caratteristiche socio-demografiche e cliniche del campione. ria. As shown in Figure 1, patients with a main diagnosis of schizophrenia spectrum and other psychotic disorders Characteristics Value and bipolar and related disorders showed a higher rate of Sex, n (%) MetS, respectively 34.1% and 29.5%. MetS was observed Male 65 (52.0) in 25% of individuals affected by depressive disorders, Female 60 (48.0) while 11.4% of patients with a main diagnosis of person- Age (years), mean (±SD) 44.94 (±13.51) ality disorders met MetS criteria. These differences were Marital status, n (%) not statistically significant. Never married 64 (51.2) The other sociodemographic and clinical features of the Married 39 (31.2) Separated or divorced 16 (12.8) Widowed 6 (4.8) Education level (years), mean (±SD) 9.94 (±3.60) Occupational status, n (%) Employed full-time 34 (27.2) Employed part-time 10 (8) House-wife 6 (4.8) Student 4 (3.2) Unemployed 53 (42.4) Retired 18 (14.4) Main diagnosis (DSM V), n (%) Schizophrenia spectrum 37 (29.6) Figure 1. Bipolar and related disorders 47 (37.6) Prevalence of MetS (NCEP ATP III modified criteria) in the main Depressive disorders 28 (22.4) different diagnoses of the sample. Prevalenza della sindrome Personality disorders 13 (10.4) metabolica nelle differenti diagnosi principali del campione.

Table II. Prevalence of MetS (NCEP ATP III modified criteria) and its components. Prevalenza della sindrome metabolica e delle sue componenti nel campione.

Criteria n (%) Abdominal obesity: > 102 cm (men) or > 88 cm (women) 64 (51.2) Hypertriglyceridaemia: ≥ 150 mg/dl or being on triglyceride-lowering medication 38 (30.4) Low HDL-C: < 40 mg/dl (men) or < 50 mg/dl (women) or being on lipid-lowering medication 72 (57.6) High blood pressure: ≥ 130 mm systolic or ≥ 85 mm diastolic or being on antihypertensive medication 36 (28.8) High fasting glucose: ≥ 100 mg/dl or being on glucose-lowering medication 25 (20) MetS (three or more criteria) 44 (35.2)

248 Metabolic syndrome in acute psychiatric inpatients: clinical correlates

Table III. Comparison between patients with MetS (n = 44) and without MetS (n = 81): sociodemographic and clinical characteristics. Confronto tra pazienti con MetS (n = 44) e senza MetS (n = 81): caratteristiche socio-demografiche e cliniche.

MetS No MetS p Sex, n (%) 0.458 Male 56.8 49.4 Female 43.2 50.6 Age (years), mean (±SD) 47.09 43.78 0.192 Positive family history for psychiatric disorders, n (%) 34.1 41.8 0.445 Positive family history for bipolar disorder, n (%) 9.1 7.6 0.744 Positive family history for CV disease, n (%) 45.2 38.5 0.560 Positive family history for diabetes, n (%) 19.0 15.4 0.616 Educational level (years), mean (±SD) 9.52 10.16 0.346 Occupational status, n (%) 0.810 Employed full-time 27.3 27.2 Employed part-time 6.8 8.6 House-wife 4.5 4.9 Student 0 4.9 Unemployed 47.7 39.5 Retired 13.6 14.8 0.701 White collar 73.3 80.8 Blue collar 26.7 19.2 Marital status, n (%) 0.786 Never married 52.3 50.6 Married 29.5 32.1 Divorced 6.8 2.5 Separated 6.8 9.9 Widowed 4.5 4.9 Locality, n (%) 0.158 Urban 2.3 9.9 Rural 97.7 90.1 Living arrangement, n (%) 1.000 Family of origin 38.6 38.3 Own family 50.0 50.6 Therapeutic facility 9.1 9.9 Homeless 2.3 1.2 Current smoking, n (%) 54.5 59.3 0.705 Lifetime smoking, n (%) 59.1 61.7 0.849 Current alcohol abuse, n (%) 18.2 4.9 0.025 Lifetime alcohol abuse, n (%) 22.7 12.3 0.200 Current substance abuse, n (%) 11.4 8.6 0.752 Lifetime substance abuse, n (%) 20.5 21.0 1.000 Main diagnosis (DSM V), n (%) 0.583 Schizophrenia Spectrum 27.7 72.3 Bipolar and related disorders 40.5 59.5 Depressive disorders 39.3 60.7 Personality disorders 38.5 61.5

(continues)

249 F. Solia et al.

Table III - Follows

MetS No MetS p Current psychiatric comorbidity, n (%) Neurodevelopmental disorders 0 2.5 0.540 Anxiety disorders 0 1.2 1.000 Obsessive compulsive and related disorders 2.3 0 0.352 Somatic symptom and related disorders 4.5 1.2 0.283 Feeding and eating disorders 0 1.2 1.000 Substance related disorders 11.4 1.2 0.020 Neurocognitive disorders 2.3 0 0.352 Personality disorders 13.6 17.3 0.799 Lifetime psychiatric comorbidity, n (%) 34.1 27.2 0.421 Neurodevelopmental disorders 0 2.5 0.540 Depressive disorders 2.3 0 0.352 Anxiety disorders 0 1.2 1.000 Obsessive compulsive and related disorders 2.3 0 0.352 Somatic symptom and related disorders 4.5 1.2 0.283 Feeding and eating disorders 0 1.2 1.000 Substance related disorders 18.2 7.4 0.081 Neurocognitive disorders 2.3 0 0.352 Personality disorders 18.2 18.5 1.000 Age of onset (years), mean (±SD) 31.03 31.70 0.804 Duration of illness (years), mean (±SD) 16.31 11.47 0.034 Lifetime aggressiveness, n (%) 56.8 46.9 0.350 Lifetime suicide attempted, n (%) 40.9 34.6 0.561 Involuntary treatment, n (%) 9.1 8.6 1.000 Duration of involuntary treatment (years), mean (±SD) 7.00 10.33 0.104 Duration of hospitalisation (years), mean (±SD) 15.56 15.23 0.866 Seasonal admission, n (%) 0.209 Autumn 56.8 40.7 Winter 22.7 40.7 Spring 6.8 7.4 Summer 13.6 11.1 Hospital discharge, n (%) 0.283 Ordinary 95.5 98.8 Patient request 4.5 1.2 Current typical antipsychotic treatment, n (%) 20.5 9.9 0.110 Current atypical antipsychotic treatment, n (%) 59.1 39.5 0.041 Current treatment with mood stabilizers, n (%) 34.1 27.2 0.421 Current treatment with antidepressants, n (%) 38.6 39.5 1.000 Current treatment with anxiolytics, n (%) 52.5 50.6 1.000 Lifetime psychiatric treatment, n (%) 95.3 86.4 0.216 Lifetime treatment with antipsychotics, n (%) 75.6 62.0 0.157 Lifetime treatment with mood stabilisers, n (%) 56.4 39.7 0.115 Lifetime treatment with antidepressants, n (%) 63.4 58.2 0.695 Lifetime treatment with anxiolytics, n (%) 88.1 72.2 0.065 Physical activity 0.069 Absent 100 86.4 Mild (< 4 hours/week) 0 7.4 Moderate (4 hours/week) 0 1.2 Intense (> 4 hours/week) 0 4.9

250 Metabolic syndrome in acute psychiatric inpatients: clinical correlates

two subgroups (with MetS and without MetS) are sum- with previous studies evaluating inpatients affected by marised in Table III. psychotic and mood disorders 30 31 and with a recent Patients who fulfilled MetS definition were more often meta-analysis in which no difference was seen in MetS characterised by current atypical antipsychotic treatment in studies directly comparing schizophrenia and bipolar (59.1% vs 39.5%; p = 0.041), current alcohol abuse disorder, or in those directly comparing bipolar disorder (18.2% vs 4.9%; p = 0.025), current psychiatric comor- to major depressive disorder 32. bidity with substance related disorders (11.4% vs 1.2%; Furthermore, we found no significant differences in the p = 0.020) and longer duration of illness (16.31 years vs prevalence of MetS between men and women. Several 11.47 years; p = 0.034). studies are consistent with our results, indicating that Next, a LogReg analysis was conducted to assess the rela- both sexes deserve the same attention 9 13. However, other tionship between the above-mentioned variables and the studies have reported higher rates of MetS in females, es- occurrence of MetS. The following explanatory variables pecially with schizophrenia 8 and recurrent major depres- were included in the analysis as independent variables: sive disorder 33, while higher MetS rates were found in current atypical antipsychotic treatment, current alcohol young males with bipolar disorder 21. Nevertheless, in the abuse, current psychiatric comorbidity with substance re- bipolar disorder population, the majority of studies have lated disorders and duration of illness. The only variable reported no differences between sex or do not report on significantly associated with the presence of MetS was it specifically 9. current atypical antipsychotic treatment (p = 0.005). We found that 59.1% of patients in the MetS subgroup were taking atypical antipsychotics (SGAs) compared Discussion and conclusions with 39.5% in the subgroup of patients without MetS. This difference was statistically significant and confirmed MetS increases the risk for cardiovascular diseases, insu- by LogReg analysis (p = 0.005). The lower proportion lin resistance and diabetes mellitus, and can lead to in- of MetS (30%) found by Centorrino and colleagues in a creased morbidity and mortality, in addition to impairing sample of antipsychotic-exposed hospitalised patients is patient adherence to medication24. These are the reasons probably due to the younger mean age of subjects; none- why, in recent years, MetS has emerged as a significant theless, patients taking antipsychotics presented MetS problem in both psychiatry and public health. There is more frequently than those who had never taken antip- thus a need to detect high-risk groups for developing sychotics 30. The association between SGAs and MetS is MetS that should especially be screened and treated. confirmed by several studies in patients with different di- This study investigated the sociodemographic and clini- agnoses. In particular, Correll and colleagues found that cal correlates of MetS in a sample of inpatients with ma- inpatients with bipolar disorder and schizophrenia who jor psychiatric disorder. More specifically, we highlighted are treated with SGAs have similarly high rates of MetS 31. whether the risk profile is the same depending on diag- It must be emphasised that in our study only current use of nostic subgroup, since several original reports as well as atypical antipsychotics was significantly associated with reviews did not provide unequivocal evidence. Moreo- MetS. This is a relevant finding, although current treat- ver, we explored whether MetS rates differ depending on ment with SGAs could underlie previous antipsychotic individual variables such as age, gender, duration of ill- treatments that are not always easy to retrace, especially ness and treatment settings in order to guide clinicians in for length and dosage. However, our results showed that monitoring and treatment decisions. exposure to atypical antipsychotics, even for a brief pe- The sample comprised 125 consecutively recruited hos- riod of time, can lead to the development or worsening pitalised patients with a main diagnosis of schizophrenia of metabolic dysregulations that can consequently give spectrum and other psychotic disorders (34.1%), bipolar rise to MetS. and related disorders (29.5%), depressive disorders (25%) Published data examining changes in weight during short- or personality disorders (11.4%). term antipsychotic treatment (4-12 weeks) of schizophre- In our sample, the overall prevalence of MetS was 35.2%. nia revealed that increases in weight and body mass in- This result is similar to that reported among patients affect- dex in subjects who received risperidone, amisulpride or ed by schizophrenia spectrum disorders 12 25-27 and mood olanzapine were clinically and statistically significantly disorders 13 28 29. Nevertheless, this is higher than the preva- greater than in those who received placebo 34. Consider- lence of MetS (23.7%) found among hospitalised psychi- ing glucose tolerance, Sacher et al. investigated the acute atric patients by Centorrino and colleagues 30. This could effects of oral administration of olanzapine and ziprasi- be due to a younger average age of the study subjects done in healthy volunteers and observed a significant de- (35.7± 13.0 years) than in sample (44.94 ± 13.51 years). crease (p < 0.001) in whole body insulin sensitivity after We did not observe a specific psychiatric disorder sig- oral intake of olanzapine (10 mg/day) for 10 days 35. nificantly associated with MetS. This finding is in line In conclusion, our study confirms the association between

251 F. Solia et al.

treatment with SGAs and increased risk of MetS among 8 McEvoy JP, Meyer JM, Goff DC, et al. Prevalence of the met- psychiatric patients independently of the diagnosis and abolic syndrome in patients with schizophrenia: baseline other clinical features. Our findings are in agreement results from the Clinical Antipsychotic Trials of Intervention with those reported in a recent meta-analysis, although Effectiveness (CATIE) schizophrenia trial and comparison our study was conducted in an Italian sample of acute with national estimates from NHANES III. Schizophr Res 2005;80:19-32. inpatients 32. These conclusions suggest a shared suscep- 9 tibility to antipsychotic-related metabolic dysregulations McIntyre RS, Danilewitz M, Liauw SS, et al. Bipolar disorder that is not primarily related to psychiatric diagnosis or and metabolic syndrome: an international perspective. J Af- fect Disord 2010;126:366-87. concomitant to other psychiatric treatment. 10 The limitations of the present study include its observa- McElroy SL, Keck Jr PE. Metabolic syndrome in bipolar dis- tional nature and the relatively small sample size, espe- order: a review with a focus on bipolar depression. J Clin Psychiatry 2014;75:46-61. cially regarding individuals primarily affected by per- 11 sonality disorders. Therefore, our conclusions are to be De Hert M, Schreurs V, Sweers K, et al. Typical and atypical antipsychotics differentially affect long-term incidence rates considered as suggestive. However, the alarmingly high of the metabolic syndrome in first-episode patients with frequency of MetS in all diagnostic subgroups and its rele- schizophrenia: a retrospective chart review. Schizophrenia vant association with current atypical antipsychotic treat- Research 2008;101:295-303. ment warrant further analyses of risk factors in patients 12 Mitchell A, Vancampfort D, Sweers K, et al. Prevalence of with major mental disorders in order to administer safer metabolic syndrome and metabolic abnormalities in schizo- and better-tolerated treatments, giving particular atten- phrenia and related disorders: a systematic review and me- tion when using atypical antipsychotics that are known ta-analysis. Schizophr Bull 2013;39:306-18. for their metabolic side effects, and preventive programs 13 Vancampfort D, Vansteelandt K, Correll CU, et al. Metabolic targeting general health among psychiatric patients. syndrome and metabolic abnormalities in bipolar disorder: a meta-analysis of prevalence rates and moderators. Am J Conflict of interests Psychiatry 2013;170:265-74. None. 14 Rosso G, Cattaneo A, Zanardini R, et al. 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The metabolic syn- Schizophr Res 2000;29;45:21-8. drome. Lancet 2005;365:1415-28. 18 3 Osby U, Brandt L, Correia N, et al. Excess mortality in bipo- Srisurapanont M, Likhitsathian S, Boonyanaruthee V, et al. Met- lar and unipolar disorder in Sweden. Arch Gen Psychiatry abolic syndrome in Thai schizophrenic patients: a naturalistic 2001;58:844-50. one year follow-up study. BMC Psychiatry 2007;23:7-14. 19 4 Birkenaes AB, Opjordsmoen S, Brunborg C, et al. The level Kraemer S, Minarzyk A, Forst T, et al. Prevalence of metabol- of cardiovascular risk factors in bipolar disorder equals that ic syndrome in patients with schizophrenia, and metabolic of schizophrenia: a comparative study. J Clin Psychiatry changes after 3 months of treatment with antipsychotics re- 2007;68:917-23. sults from a German observational study. BMC Psychiatry 2011;11:173. 5 Goldstein BI, Fagiolini A, Houck P, et al. Cardiovascular dis- 20 ease and hypertension among adults with bipolar I disorder Salvi V, D’Ambrosio V, Bogetto F, et al. Metabolic syndrome in the United States. Bipolar Disord 2009;11:657-62. in Italian patients with bipolar disorder: A 2-year follow-up study. J Affect Disord 2012;136:599-603. 6 Swartz HA, Fagiolini A. Cardiovascular disease and bipo- 21 lar disorder: risk and clinical implications. J Clin Psychiatry Salvi V, D’Ambrosio V, Rosso G, et al. Age-specific preva- 2012;73:1563-5. lence of metabolic syndrome in Italian patients with bipolar disorders. Psychiatry Clin Neurosci 2011;65:47-54. 7 Grundy SM, Cleeman JI, Daniels SR, et al. American Heart 22 Association, National Heart, Lung, and Blood Institute. Di- American Psychiatric Association. Diagnostic and Statisti- agnosis and management of the metabolic syndrome: an cal Manual of Mental Disorders. 5th edition. Arlington, VA: American Heart Association/National Heart Lung, and Blood American Psychiatric Association 2013. Institute Scientific Statement. Circulation 2005;112:2735-52. 23 Bo S, Ciccone G, Pearce N, et al. Prevalence of undiagnosed

252 Metabolic syndrome in acute psychiatric inpatients: clinical correlates

metabolic syndrome in a population of adult asymptomatic 30 Centorrino F, Masters GA, Talamo A, et al. Metabolic syn- subjects. Diabetes Res Clin Pract 2007;75:362-5. drome in psychiatrically hospitalized patients treated with 24 Tschoner A, Engl J, Rettenbacher M, et al. Effects of six sec- antipsychotics and other psychotropics. Hum Psychophar- ond generation antipsychotics on body weight and metabo- macol 2012;27:521-6. lism - risk assessment and results from a prospective study. 31 Correll CU, Frederickson AM, Kane JM, et al. Equally in- Pharmacopsychiatry 2009;42:29-34 creased risk for metabolic syndrome in patients with bipolar 25 Heiskanen T, Niskanen L, Lyytikäinen R, et al. Metabolic disorder and schizophrenia treated with second-generation syndrome in patients with schizophrenia. J Clin Psychiatry antipsychotics. Bipolar Disord 2008;10:788-97. 2003;64:575-9. 32 Vancampfort D, Stubbs B, Mitchell AJ, et al. Risk of metabol- 26 Basu R, Brar JS, Chengappa KN, et al. The prevalence of the ic syndrome and its components in people with schizophre- metabolic syndrome in patients with schizoaffective disor- nia and related psychotic disorders, bipolar disorder and der-bipolar subtype. Bipolar Disord 2004;6:314-8. major depressive disorder: a systematic review and meta- 27 Meyer JM, Nasrallah HA, McEvoy JP et al. The Clinical analysis. World Psychiatry 2015;14:339-47. Antipsychotic Trials Of Intervention Effectiveness (CATIE) 33 Kinder LS, Carnethon MR, Palaniappan LP, et al. Depres- Schizophrenia Trial: clinical comparison of subgroups sion and the metabolic syndrome in young adults: findings with and without the metabolic syndrome. Schizophr Res 2005;80:9-18. from the Third National Health and Nutrition Examination Survey. Psychosom Med 2004;66:316-22. 28 Fagiolini A, Frank E, Scott JA, et al. Metabolic syndrome in 34 bipolar disorder: findings from the Bipolar Disorder Center Parsons B, Allison DB, Loebel A, et al. Weight effects associ- for Pennsylvanians. Bipolar Disord 2005;7:424-30. ated with antipsychotics: a comprehensive database analysis. Schizophr Res 2009;110:103-10. 29 Topic R, Milicic D, Stimac Z, et al. Somatic comorbidity, metabolic syndrome, cardiovascular risk, and CRP in pa- 35 Sacher J, Mossaheb N, Spindelegger C, et al. Effects of olan- tients with recurrent depressive disorders. Croat Med J zapine and ziprasidone on glucose tolerance in healthy vol- 2013;28;54:453-9. unteers. Neuropsychopharmacology 2008;33:1633-41.

253 Original article

P. Rucci1, M. Balestrieri2 1 Department of Biomedical and Neuromotor Sciences, Alma mater Studiorum University of Bologna, Italy; 2 Psychiatric Clinic, Department of Experimental and Clinical Medical Sciences (DISM), University of Udine, Udine, Italy

Summary Results A three-factor solution provided the best goodness of fit indices. Objectives Factors were interpreted as proficiency, relational capacity and After publication of the WHO International Classification of autonomy. Factor scores were significantly higher in patients with Functioning, Disability and Health (ICF), the Mini-ICF-APP (Mini schizophrenia than in those with bipolar disorder. The ‘proficien- instrument for the observer rating according to ICF of Activities cy’ factor exhibited the strongest associations with BPRS, CGI-S and Participation in Psychological disorders) was derived and and total PSP. Moreover, correlations between Mini-ICF-APP fac- validated in three languages to assess limitations in activities or tors and PSP dimensions were in the expected direction, indicat- capacities and restrictions in participation in patients with men- ing good convergent and discriminant validity of the instrument;in tal illness. Although the Mini-ICF-APP has been demonstrated fact, the highest correlations were found between the correspond- to have sound psychometric properties, factor analytic studies ing factors/dimensions of the two instruments (proficiency with of this instrument have not been conducted, and the total score PSP socially useful activities, relational capacity with PSP personal is generally used. We aimed at examining the structure of this and social relationships, autonomy with PSP self-care) and the instrument, in order to identify possible factors, which would lowest correlations were observed with PSP dimension ‘disturbing allow a more sensitive measurement of an individual’s specific and aggressive behaviour, that is not assessed in the Mini-ICF-APP. limitations. Conclusions The factors extracted are clearly interpretable and have conver- Methods gent/discriminant validity. Our findings may have clinical impli- Patients with schizophrenia or bipolar disorder attending a cations, as the distribution of factors distinguishes the two patient community mental health center were recruited consecu- groups, which may require different interventions to achieve an tively over an index period and underwent standardised as- optimal therapeutic response. sessment, including the 13-item Mini-ICF-APP 24-item and Personal and Social Performance scale and the Brief Psychi- Key words atric Rating Scale (BPRS-24). Factor analysis with maximum likelihood estimation and oblique rotation was performed on Exploratory factor analysis • Schizophrenia • Bipolar disorder • Capacity Mini-ICF-APP items. • Activity • Participation

Introduction formance’’, i.e. what a person does, and ‘‘capacity’’, i.e. what a person can do. Capacity and even more disorders Severe mental illness is often associated with problems of capacity are defined in relation to a ‘‘uniform or stand- in social or occupational adjustment and functioning 1-4. According to the bio-psycho-social model of the Interna- ard environment’’ and ‘‘reflect the environment adjusted tional Classification of Functioning, Disability and Health, ability of the individual’’. ICF 5, a person’s illness is the result of the complex interre- Participation is involvement in a life situation and is de- lations between functions, capacities, context factors and fined as the degree to which a person can fulfil role re- participation. Activities are defined as ‘‘the execution of quirements in his/her job, family, or leisure time. This is a task or action’’. There is a differentiation between ‘‘per- partly dependent on ‘‘context factors’’, which define the

Correspondence Paola Rucci, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, via San Giacomo 12, 40126 Bologna, Italy • Tel. +39 051 2094808 • E-mail: [email protected]

254 Journal of Psychopathology 2015;21:254-261 Exploratory factor analysis of the Mini instrument for the observer rating according to ICF of Activities and Participation in Psychological disorders (Mini-ICF-APP) in patients with severe mental illness

type and complexity of requirements that have to be ful- The Mini-ICF-APP consists of 13 items that explore: (1) filled and which therefore must also be described and adherence to regulations, (2) planning and structuring of taken into account. tasks, (3) flexibility, (4) competency, (5) judgement, (6) Since the publication of the ICF, research on the meas- endurance, (7) assertiveness, (8) contacts with others, (9) urement of social and occupational consequences of ill- integration, (10) intimate relationships, (11) spontane- nesses has increased 4 6-8. In the field of mental disorders, ous activities, (12) self-care, (13) mobility. Each item is the relation between functions, capacities and participa- rated on a five-point Likert scale (0: no disability, 1: mild tion poses special problems 9-10. Relevant domains of ca- disability, 2: moderate disability, 3: severe disability, 4: pacities that may be impaired especially in the presence total disability). A total score is obtained by adding the of mental illness are adherence to regulations, planning item scores. and structuring of tasks, flexibility, endurance, assertive- The Mini-ICF-APP rater collects information on the ness, self-maintenance, mobility, or competence to make “uniform standard environment” or the social reference judgements or decisions. group, whichever applies to the case. The appraisal is The Mini-ICF-APP 9-12 is a shortened version of the ICF based on available information (self-reports, information that also takes into account the definitions of the Gronin- from the family, colleagues, friends, caregivers and health gen Social Disabilities Schedule II 13. It has been designed staff involved in the case management, from clinical ob- to be a clinician-rated instrument to assess limitations of servations and from medical exams or standardised tests) capacities and/or participation restrictions in patients about the person and his/her living condition. The Mi- with mental disorders. ni-ICF-APP assessment requires sufficient knowledge of It was originally developed in German 12, later validated the proband. This is the usual situation of people in care in English and Italian 14-15, and recently translated to Geor- with community mental health services. When sufficient gian 16. The Italian validation study, carried out in patients knowledge of the patient has been acquired, compilation diagnosed with schizophrenia, major depression, bipolar of the Mini-ICF-APP requires about 20 min. The Personal and Social Performance Scale (PSP) 17-19 I disorder and anxiety disorders, showed that MINI-ICF- is a clinician-rated tool designed for completion by APP has a good inter-rater and test-retest reliability, and trained clinical staff. PSP has been developed through a high correlation with psychopathology measures (BPRS focus groups and reliability studies on the basis of the and CGI-S) and other measures of functioning such as social functioning component of the DSM-IV Social and the Personal and Social Performance Scale (PSP) and the Occupational Functioning Assessment Scale (SOFAS). Social and Occupational Functioning Assessment Scale Patient functioning is assessed in four main areas: ‘so- (SOFAS) 15. cially useful activities’, ‘personal and social relation- The aim of the present study is to examine the structure ships’, ‘self-care’ and ‘disturbing and aggressive behav- of the instrument in patients with severe mental illness in iours’. Difficulty in each area is rated on a single item order to identify possible factors that may support clinical using a six-point scale, where lower ratings indicate bet- and research efforts to summarise and monitor limitations ter functioning. A global item is rated by the interviewer, in patient capacity and participation restriction to be tar- ranging from 1 to 100 in 10-point intervals, where lower geted in rehabilitation interventions. scores indicate poorer functioning. The PSP global score incorporates ratings for the four main areas, as well as Methods levels of functioning in other areas, to adjust the precision of the rating within the ten-point intervals. This One hundred patients (50 with schizophrenia and 50 instrument has been demonstrated to have sound psy- with bipolar I disorder) were consecutively recruited chometric properties and has been previously used in a from those attending the Community Mental Health Cen- number of studies in patients with severe mental illness tre (CMHC) of North-Udine (Italy). The diagnosis was as- in Italy and elsewhere 20-25. signed on clinical grounds by psychiatrists working in the The Brief Psychiatric Rating Scale (BPRS) is a well-known CHMC using DSM-5 criteria. All patients signed a written clinician-rated tool designed to assess the severity of psy- consent to participate. The study was approved by the Lo- chopathology 26. The BPRS items focus on symptoms that cal Ethics Committee. are common in patients with psychotic disorders and mood disorders. Items range from 1 to 7, where 1 denotes Instruments the absence of the symptom and 7 the highest severity. In Patient assessment included a socio-demographic form, the present study, we used the expanded (24-item) ver- Mini-ICF-APP, Personal and Social Performance Scale, sion of the scale 27. Brief Psychiatric Rating Scale (BPRS) and Clinical Global The Clinical Global Impression Scale (CGI) is a 3-item Impression Scale (CGI-S). observer-rated scale that measures illness severity (CGI-

255 P. Rucci, M. Balestrieri

S), global improvement or change (CGI-C) and thera- Results peutic response 28. The illness severity and improvement sections of the instrument are used more frequently than Characteristics of the study participants are provided in the therapeutic response section in both clinical and re- Table I by diagnostic group. They had a mean age of 49.7 search settings. In this study only the CGI-S has been years, 61% were male with a mean duration of illness used. of 19.7 years. The large majority of patients with schizophrenia were single, 52% had at least a high school di- Statistical analysis ploma, 22% were employed and 88% were living with their family or independently. In patients with bipolar dis- Exploratory factor analysis of MINI-ICF-APP items was order, 30% were single, 67% had at least a high school performed using a robust weighted least square estima- diploma, 32% were employed and 94% were living in- tor to take into account the ordinal-level measurement dependently. of items. For this analysis, 2 missing items in 2 cases At the time of the assessment, 91% were treated pharma- were replaced with mean values. Kaiser-Meier-Olkin cologically and 46% had been admitted to the hospital index was used to measure sampling adequacy. This at least once; 64% of patients with schizophrenia were measure varies between 0 and 1. Values above 0.8 are involved in a psychosocial rehabilitation program. excellent and indicate that the patterns of correlations are relatively compact and factor analysis should yield Factor analysis distinct and reliable factors. The number of factors to be extracted was determined using goodness of fit indices. KMO measure was 0.92, indicating an excellent sampling These included the χ² test and the root mean square er- adequacy for factor analysis. Therefore, factor analysis ror of approximation (RMSEA). A non-significant χ² test was conducted and 1, 2, 3 factor solutions were derived. denotes a good fit to the data. RMSEA values < 0.05 The three-factor solution accounted for 75% of item vari- indicate good model fit and values between 0.05 and ance and had the best fit to the data (Table II), as shown 0.08 indicate a reasonable error of approximation in the by the non-significant χ² value and a satisfactory RMSEA population. index. Factor loadings to the three factors, arranged in de- Oblique rotation was performed using the promax meth- creasing order by factor, are shown in Table III. Loadings od, under the hypothesis that the factors to be extracted lower than 0.30 were not reported. were correlated. Factor 1, including 7 items, was interpreted as ‘profi- Standardised factor scores were calculated using the re- ciency’, since the items that load on it represent the cog- gression method. These scores are expressed as Z scores nitive and performance-related skills necessary to begin (mean 0 and standard deviation 1) and are an estimate and maintain a task such as a work or a commitment in of the score each subject would have on each fac- general. The items with the highest loading on this factor tor, if it were measured directly. Mann-Whitney test or were endurance, adherence to regulations and planning Spearman›s correlation coefficient was used as appropri- and structuring of tasks. ate to analyse the relationship of factor scores with diag- Factor 2, including 3 items, contacts with others, integra- nosis, psychosocial functioning (PSP scores) and severity tion, and intimate relationships, was interpreted as ‘re- of psychopathology (BPRS and CGI-S). Five multivariate lational capacity’ and lastly factor 3, including mobility, analyses of variance were conducted to examine the rela- self-care, and spontaneous activities was defined as ‘au- tionship of factors with demographic characteristics (age, tonomy’. gender, marital status, working status and living arrange- Factors were correlated with each other, supporting the ment). In these analyses, the dependent variables were choice of using an oblique rotation (1 with 2 Spearman’s the factors and the independent variables were the demo- ρ = 0.719, 1 with 3 ρ = 0.531, 2 with 3 ρ = 0.532). graphic characteristic of interest, diagnosis and interaction between diagnosis and demographic characteristic. Convergent and discriminant validity of factors Diagnosis was included in the model to take into account All MINI-ICF-APP factors were positively and significantly the different distribution of demographic characteristics correlated with severity of illness, and negatively with the between diagnostic groups. Marital status was coded as total PSP (because it is scored in the opposite direction) (Ta- single, married, divorced/separated/widow;working stable IV). The ‘proficiency’ factor exhibited the strongest asso- tus was coded as employed, unemployed, student/house- ciations with BPRS (ρ = 0.696), CGI-S (ρ = 0.612) and total wife, retired and living arrangement as self-sufficient vs. PSP (ρ = -0.761). Moreover, correlations between MINI-ICF- living in a residential facility. APP factors and PSP dimensions were in the expected direc- All analyses were performed using MPLUS and IBM SPSS tion, indicating good convergent and discriminant validity Statistics 20.0 for Windows. of the instrument;in fact, the highest correlations were found

256 Exploratory factor analysis of the Mini instrument for the observer rating according to ICF of Activities and Participation in Psychological disorders (Mini-ICF-APP) in patients with severe mental illness

Table I. Characteristics of the sample. Data are reported as percentages or as mean ± SD. Caratteristiche del campione. I dati sono riportati come percentuali, o medie ± DS.

Characteristics Schizophrenia Bipolar disorder Total (N = 50) (N = 50) (N = 100) Gender Males 74 48 61 Females 26 52 39 Age (mean ± SD) 41.1 ± 10.5 58.3 ± 13.1 49.7 ± 14.7 Marital status Single 80 30 55 Married 12 38 25 Separated/divorced 8 32 20 Education Less than primary school 0 4.3 2.1 Primary school 8 13.1 10.4 Secondary school 40 5.2 28.1 High school diploma 46 47.8 46.9 University degree 6 19.6 12.5 Living situation Self-sufficient/with relatives 88 94 91 Clinic/Residential facility 12 6 9 Occupation Employed 22 32 27 Temporary job 4 4 4 Unemployed 40 14 27 Housewife/student 10 12 11 Retired 24 38 31 Previous psychiatric contacts No 36 16 26 Yes 64 84 74 Previous admissions to hospitals No 60 48 54 Yes 40 52 46 Previous compulsory admissions No 8 20 14 Yes 92 80 86 Previous use of psychotropic drugs No 34 26 30 Yes 66 74 70 Current use of psychotropic drugs No 8 10 9 Yes 92 90 91 Social network Absent 6.1 10 8.1 Family/friends 81.6 86 83.8 Public/co-op services 12.2 4 8.1 Perception of social support Positive 58.3 58.7 58.5 Negative 31.2 17.4 24.5 Not available 10.4 23.9 17.0 Presence of legal/administrative representative No 74.4 75 74.7 Yes 25.6 25 25.3

(continues)

257 P. Rucci, M. Balestrieri

Table I - Follows

Characteristics Schizophrenia Bipolar disorder Total (N = 50) (N = 50) (N = 100) Stressful events in the last 12 months No 49 48 48.5 Yes 51 52 51.5 Alcohol/substance abuse No 76 80 78 Yes 24 20 22 Ongoing rehabilitation program No 36 91.3 62.5 Yes 64 8.7 37.5 Funded project No 74.2 50 70.3 Yes 25.8 50 29.7 Duration of illness (mean ± SD) 17.4 ± 10.0 22.0 ± 11.8 19.7 ± 11.1 Duration of untreated illness (mean±SD) 13.1 ± 10.3 15.1 ± 11.9 14.1 ± 11.1 PSP scoring: Socially useful activities 3.10 ± 1.15 1.86 ± 1.32 2.48 ± 1.38 Personal and social relationships 3.00 ± 1.07 1.86 ± 1,07 2.43 ± 1.21 Self-care 1.36 ± 1.27 0.70 ± 0.86 1.03 ± 1.13 Disturbing/aggressive behaviours 1.78 ± 1.53 0.84 ± 0.98 1.31 ± 1.36 Total score 42.0 ± 17.3 59.8 ± 18.9 50.9 ± 20.1 CGI-S severity score 5.6 ± 1.0 4.6 ± 1.2 5.1 ± 1.2 BPRS total score 68.9 ± 20.4 50.0 ± 19.6 59.0 ± 22.3

Table II. after adjusting for diagnosis. The autonomy factor was as- Goodness of fit indices for the 1, 2, 3 factor solutions. Indici di sociated with living arrangement (F = 2.89, p < 0.05), indi- bontà di adattamento per le soluzioni ad 1,2,3 fattori. cating that patients living in a residential facility had lower levels of autonomy and working status (employed had Solution lower autonomy than unemployed, F = 197, p < 0.05). 1 factor 2 factors 3 factors Proficiency and relational capacity were not associated χ² (p) 217.9 155.3 56.8 with working status and living arrangement. (< 0.001) (< 0.001) (0.06) RMSEA 0.153 0.063 0.059 Discussion The findings of the present study indicate that three factors underlie the 13 Mini-ICF-APP items. between the corresponding factors/dimensions of the two The factors identified (proficiency, relation capacity and instruments (proficiency with PSP socially useful activities, autonomy) proved to have good convergent and discri- ρ = 0.780, relational capacity with PSP personal and so- minant validity with the PSP dimensions, indicating that cial relationships, ρ = 0.770, autonomy with PSP self-care, they measure psychometrically robust constructs. In ad- ρ = 0.803) and the lowest correlations were observed with dition, they appear to be consistent with a conceptual PSP dimension ‘disturbing and aggressive behaviour, which model of psychosocial assessment of functional and paris not assessed in the MINI-ICF-APP. ticipation capacities that is easily understandable and ap- Factor scores were significantly higher in patients with plicable to rehabilitation programs. schizophrenia compared with those with bipolar disorder The factors were positively correlated with psychopathol- (Mann-Whitney test, p < 0.001). ogy, as assessed by the BPRS and the CGI-S. These results confirm our previous findings, indicating a high correla- Relationship of factors with demographic variables tion of Mini-ICF-APP with BPRS and CGI-S 15, and those Multivariate analyses of variance revealed that age, gender of Schaub et al. 29, who found a high correlation between and marital status were unrelated with the three factors, PSP and both Mini-ICF-APP and PANSS five-factor model

258 Exploratory factor analysis of the Mini instrument for the observer rating according to ICF of Activities and Participation in Psychological disorders (Mini-ICF-APP) in patients with severe mental illness

Table III. Factor loadings to the three factors, arranged in decreasing order. Pesi fattoriali rispetto ai tre fattori, ordinati in modo decrescente.

1 2 3 Proficiency Relational capacity Autonomy Endurance 0.933 Adherence to regulations 0.921 Task planning 0.852 Flexibility 0.821 Judgement 0.661 Assertiveness 0.601 Competency 0.597 Contacts with others 0.933 Integration 0.815 Intimate relationships 0.705 Mobility 0.847 Self-care 0.757 Spontaneous activities 0.619

Table IV. Spearman’s correlations (ρ) between factor scores, psychosocial functioning (PSP) and psychopathology variables (BPRS e CGI-S). Coefficienti di correlazione di Spearman (ρ) tra i punteggi fattoriali, il funzionamento psicosociale (PSP) e le variabili che misurano la psicopatologia (BPRS e CGI-S).

PSP socially PSP personal PSP self-care PSP disturbing PSP total BPRS total CGI-S useful and social and aggressive activities relationships behaviours Proficiency 0.780 * 0.756 * 0.551 * 0.585 * -0.761 * 0.696 * 0.612 * Relational capacity 0.673 * 0.770 * 0.563 * 0.431 * -0.665 * 0.571 * 0.572 * Autonomy 0.680 * 0.650 * 0.803 * 0.337 * -0.668 * 0.509 * 0.558 * * p < .01

scores. In particular, in the present study we found that of patients or after a reasonable time period (e.g. a few severity of illness was most strongly associated with the months) from the first examination, when a sufficient num- first factor ‘proficiency’, which explores capacity limita- ber of mental-health operators remember the characteristics tions, i.e. the cognitive abilities and skills required to per- of the patients at a specific point in time. Thus, it is suitable form daily tasks and to work. for sharing information among a multidisciplinary team of Lastly, the MINI-ICF-APP factors had good known-group carers, such as those working in mental health community- validity because capacity limitations were higher in pa- based services, who know the degree of restrictions of the tients with schizophrenia than in patients with bipolar dis- subject on different activities or participation. The main order, as expected based on the differential achievement advantage of Mini-ICF-APP over other existing instruments of social and work milestones between these groups. such as the PSP or the Global Assessment of Functioning The autonomy factor was associated with working status (GAF) is the possibility to detail the restrictions that can hin- and living arrangement. The results are consistent with der the full accomplishment of the daily life duty. Thus, the the expectation that being unemployed and living in a MINI-ICF-APP fulfils the need of an accurate description of residential facility entails lower autonomy. the specific restrictions of the proband, which is a consoli- The MINI-ICF-APP can be used in everyday clinical prac- dated principle of rehabilitation programs. tice, and can be administered after an in-depth assessment The factors derived in the present study can be useful for

259 P. Rucci, M. Balestrieri

research purposes, to monitor changes in limitations and 10 Baron S, Linden M. Disorders of functioning and disorders participation restriction over time and to establish the ef- of competence in relation to sick leave in mental disorders. fectiveness of rehabilitation programs targeted to specific Int J Soc Psychiatry 2009;55:57-63. subgroups of patients. 11 Linden M, Baron S. Das Mini-ICF-Rating für Psychische Stö- Our results should interpreted keeping in mind some lim- rungen (Mini-ICF-P). Ein Kurzinstrument zur Beurteilung itations. First, the sample size was relatively small to con- von Fähigkeitsstörungen bei psychischen Erkrankungen. Re- duct a factor analysis. However, although some authors habilitation 2005;44:44-151. recommend a 10:1 patient/items ratio, a 5:1 ratio is in 12 Linden M, Baron S, Muschalla B. (Mini-ICF-Rating für Ak- general sufficient when the sampling adequacy is good, tivitäts- und Partizipationsstörungen bei Psychischen Er- as is the case in the present study. The sample size was krankungen (Mini-ICF-APP). Bern: Hogrefe Verlag Hans Hu- ber 2009 (Italian translation: Linden M, Baron S, Muschalla also limited to draw conclusions about the relationship of B. Mini-ICF-APP. Uno strumento per la valutazione dei defi- factors with demographic characteristics because some cit di attività e partecipazione nei disturbi psichici. Balestri- subgroups had very few patients. Therefore, confirmation eri M, Maso E, eds. Firenze: Giunti OS editore 2012). of our results is warranted in larger samples. 13 Wiersma D, DeJong A, Ormel J. The Groningen social dis- Moreover, patients were not administered a structured ability schedule:development, relationship with ICIDH, and diagnostic interview. Nonetheless, they had on average psychometric properties. Int J Rehab Res 1988;11:213-24. a 20-year duration of illness and were well known to the 14 Molodynski A, Linden M, Juckel G, et al. The reliability, staff of the community mental health service. validity, and applicability of an English language version of the Mini-ICF-APP. Soc Psychiatry Psychiatr Epidemiol Conflict of interests 2013;48:1347-54. None. 15 Balestrieri M, Isola M, Bonn R, Tam T, Vio A, Linden M, Maso E. Validation of the Italian version of Mini-ICF-APP, References a short instrument for rating activity and participation restrictions in psychiatric disorders. Epidemiol Psychiatr Sci 1 Hensing G, Brage S, Nygård JF, et al. Sickness absence 2013;22:81-91. with psychiatric disorders – an increased risk for margin- 16 de Boer W, Danelia M, Zurabashvili D, et al. Development alisation among men? Soc Psychiatry Psychiatr Epidemiol of a training programme in disability assessment methodol- 2000;35:335-40. ogy based on international classification of functioning, dis- 2 Savikko A, Alexanderson K, Hensing G. Do mental health ability and health (ICF) for psychiatric disability claims in problems increase sickness absence due to other diseases? Georgia. Georgian Med News 2014;232-233:74-7. Soc Psychiatry Psychiatr Epidemiol 2001;36:310-16. 17 Morosini PL, Magliano L, Brambilla L, et al. Development, 3 Linden M, Weidner C. Arbeitsunfähigkeit bei psychischen reliability and acceptability of a new version of the DSM- Störungen. Nervenarzt 2005;76:1421-31 IV Social and Occupational Functioning Assessment Scale 4 Burns T, Patrick D. Social functioning as an outcome meas- (SOFAS) to assess routine social functioning. Acta Psychiatr ure in 381 schizophrenia studies. Acta Psychiatrica Scandi- Scand 2000;1001:323-9. navica 2007;116:403-18. 18 Juckel G, Schaub D, Fuchs N, et al. Validation of the Per- 5 World Health Organization. International Classification of sonal and Social Performance (PSP) Scale in a German sam- Functioning, Disability and Health (ICF). Geneva: WHO ple of acutely ill patients with schizophrenia. Schizophr Res Press 2001. 2008;104:287-93. 6 Boldt C, Brach M, Grill E, et al. The ICF categories identified 19 Patrick DL, Burns T, Morosini P, et al. Reliability, validity and in nursing interventions administered to neurological pa- ability to detect change of the clinician-rated Personal and tients with post-acute rehabilitation needs. Disabil Rehabil Social Performance scale in patients with acute symptoms of 2005;27:420-31. schizophrenia. Curr Med Res Opin 2009;25;325-38. 7 Cieza A, Stucki G. Content comparison of Health Related 20 Gigantesco A, Vittorielli M, Pioli R, et al. The VADO ap- Quality of Life (HRQOL) instruments based on the Inter- proach in psychiatric rehabilitation: a randomized con- national Classification of Functioning, Disability and Health trolled trial. Psychiatr Serv 2006;57;1778-83. (ICF). Qual Life Res 2005;14:1225-37. 21 Galderisi S, Rossi A, Rocca P, et al. The influence of illness- 8 Stier-Jarmer M, Grill E, Ewert T, et al. ICF Core Set for pa- related variables, personal resources and context-related tients with neurological conditions in early post-acute reha- factors on real-life functioning of people with schizophrenia. bilitation facilities. Disabil Rehabil 2005;27:389-96. World Psychiatry 2014;13:275-87. 22 9 Baron S, Linden M. The role of the “International Classi- Apiquian R, Ulloa ER, Herrera-Estrella M, et al. Validity of fication of Functioning, Disability and Health, ICF” in the the spanish version of the personal and social performance classification of mental disorders. Eur Arch Psychiatry Clin scale in schizophrenia. Schizophr Res 2009;112:181-6. Neurosci 2008;255(Suppl. 5):81-85. 23 Barbato A, Parabiaghi A, Panicali F, et al.; Progres-Acute

260 Exploratory factor analysis of the Mini instrument for the observer rating according to ICF of Activities and Participation in Psychological disorders (Mini-ICF-APP) in patients with severe mental illness

Group. Do patients improve after short psychiatric admission? 27 Ventura J, Nuechterlein, KH, Subotnik KL, et al. Symptom A cohort study in Italy. Nord J Psychiatry 2011;65:251-8. dimensions in recent-onset schizophrenia and mania: a 24 Nicholl D, Nasrallah H, Nuamah I, et al. Personal and social principal components analysis of the 24-item Brief Psychiat- functioning in schizophrenia: defining a clinically meaning- ric Rating Scale. Psychiatry Res 2000;97:129-35. ful measure of maintenance in relapse prevention. Curr Med 28 Guy W. ECDEU Assessment Manual for Psychopharmacol- Res Opin 2010;26:1471-84. ogy. Rockville, MD: U.S. Department of Health, Education, 25 Lindenmayer JP, McGurk SR, Khan A, et al. Improving social and Welfare 1976. cognition in schizophrenia: a pilot intervention combining 29 Schaub D, Brüne M, Jaspen E, et al. The illness and everyday computerized social cognition training with cognitive reme- living: close interplay of psychopathological syndromes and diation. Schizophr Bull 2013;39;507-517. psychosocial functioning in chronic schizophrenia. Eur Arch 26 Overall JE, Gorham DR. The brief psychiatric rating scale. Psychiatry Clin Neurosci 2011;261:85-93. Psychol Rep 1962;10:799-812.

261 Original article

Can we modulate obsessive-compulsive networks with neuromodulation? Neuromodulazione dei network ossessivo-compulsivi: è possibile?

S. Pallanti1 2 3, G. Grassi3, A. Marras3 , E. Hollander2 1 UC Davis School of Medicine, Department of Psychiatry and Behavioral Sciences, Sacramento, CA, USA; 2 Albert Einstein College of Medicine and Montefiore Medical Center, New York, USA; 3 University of Florence, Department of Neuroscience, Florence, Italy

Summary on obsessive-compulsive symptoms have been less investi- Neuromodulation techniques represent a network pathway-ori- gated, and the bulk of the available data is from case reports. ented treatment that can be considered as a promising tool in Nevertheless, promising results are shown for cathodal stimu- the achievement of “precision medicine” and a research domain lation of the OFC, while stimulation of the dorsolateral pre- criteria -based approach to treat several psychiatric disorders, frontal cortex (DLPFC) failed to improve symptomatology. The including obsessive-compulsive disorder (OCD). aim of this review is to discuss the effects of both invasive and Both repetitive transcranial magnetic stimulation (rTMS) tar- non-invasive neuromodulation techniques in OCD, focusing on geting the pre-supplementary motor area (pre-SMA), deep its core dysfunctional networks such as prefrontal-striatal and TMS (dTMS) targeting the orbitofrontal cortex (OFC) and SMA networks. deep brain stimulation (DBS) targeting the nucleus accumbens (Nacc) and ventral capsule/ventral striatum (VC/VS) seem to Key words be effective in improving obsessive-compulsive symptoms and Obsessive-compulsive disorder • Neuromodulation • Transcranial mag- to restore dysfunctional prefrontal-striatal and pre-motor cir- netic stimulation • Transcranial direct current stimulation • Deep brain cuitries. Transcranial direct current stimulation (tDCS) effects stimulation

Introduction dysfunctions can/will be identified by current or future tools of neuroscience: its ultimate goal is “precision medi- Current systems of classification in psychiatry, such as the cine” for psychiatry, or, in other words, a diagnostic re- DSM-5 and the ICD-10, are based on a categorical ap- finement based on a deeper understanding of the circuit- proach that often fails to align to emerging findings from ries and networks of psychiatric disorders considered to genetics and neuroscience and do not capture the under- be responsible for brain diseases 2. 1 lying mechanism of dysfunction . Moreover, despite the Neuromodulation techniques represent a network path- rigid boundaries between disorders, the presence of clini- way-oriented treatment that can be considered as a prom- cally observed overlaps and neutral territories give rise to ising tool in the achievement of “precision medicine” and hybrid diagnoses, such as atypical or mixed forms. This a RDoC-based approach to treat several psychiatric dis- results in limited knowledge regarding the neurobiologi- orders. Both invasive (deep brain stimulation, DBS) and cal underpinnings of most psychiatric disorders and their non-invasive (transcranic magnetic stimulation, TMS, and exact pathophysiology. In the last years, the United States transcranial direct current stimulation, tDCS) techniques NIMH (National Institute of Mental Health) launched the have been used in the last years in order to modulate sev- Research Domain Criteria (RDoC) project as an attempt eral dysfunctional networks underlying different psychiat- to overcome the limitations of current diagnostic systems ric disorders and to optimise treatment 3. and to “develop, for research purposes, new ways of clas- Non-invasive techniques (TMS and tDCS) are able to mod- sifying mental disorders based on dimensions of observ- ulate cortical and brain regions with electromagnetic fields able behavior and neurobiological measures” 1. Therefore, or direct electrical currents over the scalp, which can ei- RDoC projects aim to create a framework integrating the ther increase or decrease cortical excitability in relatively most recent contributions in neuroscience and genomics focal areas depending on stimulation parameters. Repeti- to guide future classification schemes. The RDoC project tive TMS (rTMS) is a TMS protocol usually employed for is based on the idea that psychiatric disorders result from treatment: high-frequency stimulation (≥5 Hz) stimulation underlying alterations in neural circuits, and that these is usually excitatory, whereas low-frequency (< 5 Hz) is

Correspondence Stefano Pallanti, via delle Gore 2H, 50134 Firenze, Italia • Tel. +39 055 7949707 • Fax +39 055 581051 • E-mail: [email protected]

262 Journal of Psychopathology 2015;21:262-265 Can we modulate obsessive-compulsive networks with neuromodulation?

usually inhibitory 4, with effects on the brain such as long Neuromodulation targeting prefrontal-striatal term potentiation (LTP) and long term depression (LTD) 5. networks The electromagnetic field generated from an rTMS coil In the last years increased functional connectivity be- placed over the scalp is able to reach a depth of 2 cm, tween the orbito-frontal cortex (OFC) and the ventral stri- so that some deep areas of the brain cannot be targeted: atum (VS) has been reported in patients with OCD 13 14. for this reason, a coil with greater intracranial penetration These data have also been confirmed by recent optoge- has been developed to reach limbic areas, administrat- netic studies on animal models of OCD 15. Repeated stim- ing a protocol of stimulation termed deep TMS (dTMS). ulation of the OFC-ventromedial striatum (VMS) projec- tDCS uses direct electrical currents to stimulate specific tions in mice using optogenetic techniques that increased parts of the brain. A constant, low intensity current is the firing of postsynaptic VMS cells and the frequency of passed through two electrodes placed over the head, over-grooming behaviour, which represents OCD-like which modulates the membrane potential depending on symptoms in mice 15. Recently, the hyperactive connec- the type of electrode application. In fact, anode is able to tion from the OFC to the VS has been further confirmed facilitate the depolarisation of neurons, while in contrast by a resting-state fMRI study performed in non-medicat- cathode hyperpolarises the resting membrane potential, ed OCD patients and healthy volunteers 16. This fronto- reducing the neuronal firing 6. striatal hyperconnectivity has been targeted with several On the other hand, DBS is an invasive technique, which neuromodulation techniques, such as DBS, repetitive and requires the stereotactical implantation of uni/bilateral deep TMS, and tDCS. electrodes in specific target brain regions through a neu- Several studies have investigated the effectiveness of DBS rosurgical procedure. Therefore, it resembles a kind of targeting different spots of prefrontal-striatal networks. brain pacemaker that electrically stimulates specific ar- DBS targeting the NAc and the ventral capsule/ventral eas to achieve a reduction in symptoms. stiatum (VC/VS) seems to be the most promising 3. In a Both invasive and non-invasive procedures have been in- relevant paper of 2013, Figee et al. investigated NAc- vestigated in a broad range of neuropsychiatric disorders, frontal network modulation of DBS in OCD patients us- among which, obsessive-compulsive disorder (OCD) and ing functional magnetic resonance imaging (fMRI) and related disorders. Even if still unclear, the neurobiology of electroencephalography (EEG) in a DBS-ON/OFF para- OCD is one of the most characterised among all psychi- digm 17. In this study DBS was effective in reducing OCD atric disorders. Thus, the aim of this paper is to review the symptoms and restored blunted NAc activity during a effects of neuromodulation techniques on dysfunctional reward anticipation task. Moreover, DBS reduced the networks in OCD, focusing on its core dysfunctional net- hyperconnectivity between the NAc and prefrontal areas works such as prefrontal-striatal and supplementary mo- (the lateral prefrontal cortex (lPFC) and medial prefron- tor area (SMA) networks 3 7. tal cortex (mPFC). DBS-induced changes in connectivity were correlated with changes in obsessions and compul- Main dysfunctional networks in OCD sions, suggesting that DBS reduces OCD symptoms by decreasing excessive frontostriatal connectivity. Finally, Structural and functional neuroimaging research has the authors also found that DBS attenuated the increase shown that the pathophysiology of OCD is associated in low-frequency activity elicited by symptom-provoking with dysfunction of the orbitofronto-striato-pallido-tha- stimuli, suggesting that DBS tapered the frontal brain re- lamic circuitry, including several prefrontal and subcor- sponse evoked by symptom-provoking events 17. tical areas 8. More recently, several studies have shown Several TMS and one tDCS studies targeted the prefron- reward circuitry and frontal areas dysfunctions 9, so that tal-striatal network stimulating the dorso-lateral prefron- the neurobiology of OCD has shifted from the anxiety- tal cortex (DLPFC) in OCD patients. However, a recent avoidance paradigm – involving amygdala and prefrontal meta-analysis shows that rTMS over both the left and cortex networks dysfunctions – to the reward-dysfunction right DLPFC does not seem to be effective in reducing one, involving nucleus accumbens (NAc) and frontal net- obsessive-compulsive symptoms 7. Moreover, a study work dysfunctions 9 10. Moreover, several studies showed with tDCS over the DLPFC failed to show benefits for the relevance of networks involving pre-motor areas, obsessive-compulsive symptoms 18. In fact, in this study such as the pre-supplementary motor area (pre-SMA), in the authors reported that cathodal-tDCS applied over the regulating inhibitory control functions (response inhibi- DLPFC decreased anxiety and depressive symptoms, but tion and error monitoring) in OCD patients 11 12. There- failed to alleviate obsessive-compulsive symptoms in a fore, neuromodulation studies have focused on these two patient with treatment-resistant OCD 18. main dysfunctional networks (prefrontal-striatal and pre- On the other hand, encouraging results has emerged by motor networks). a deep-TMS study that explored the effects of dTMS over

263 S. Pallanti et al.

the left OFC 19. The authors found that low-frequency dT- and exposure and response prevention (ERP) for an OCD MS resulted in significant reductions (> 25 %) on YBOCS patient with minimal response to psychopharmacologi- score for 8 of 16 patients and a reduction > 35 % for 4 cal treatment. The combined protocol showed effective- of 16 patients, with benefits lasting up to 10 weeks after ness for all obsessive-compulsive symptom dimensions the end of dTMS treatment. In addition, the effectiveness and resulted in large and rapid reduction in symptoms. of OFC stimulation seems to be supported by a recent This suggests the existence of synergistic effects between tDCS study that reported a 26 % reduction in YBOCS one TMS and ERP that should be further investigated: ERP month after the completion of 10 sessions of cathodal may mitigate the shortcomings effects of pre-SMA rTMS tDCS over the left OFC in a single patient with treatment- in OCD and TMS may improve the speed of ERP. Of note, resistant OCD 20. high-frequency rTMS over the left DLPFC has also been employed to enhance the effects of cognitive behavioural Neuromodulation targeting pre-SMA networks therapy (CBT), since its ability to induce long-term poten- 29 Recently, both neuroimaging and neurophysiological tiation has prompted further investigation and develop- studies have focused on supplementary motor area (SMA) ment of combined treatment options. hyperactivity in the clinical expression of OCD SMA networks seem to be involved in two main cognitive endo- Conclusions phenotypes of OCD. In fact, pre-SMA (the more ventromedial region of the SMA) is involved in the cognitive Neuromodulation techniques allow a network pathway- process of response inhibition and has been shown to be oriented treatment for several psychiatric disorders, in- hyperactive in OCD patients during response inhibition cluding OCD. The identification of the core dysfunctional tasks 11. Response inhibition deficit is a consistent finding networks of the disorder and key nodes to target is crucial in the OCD literature and has been proposed as the cog- to optimise treatment. A range of recent investigations nitive endophenotype since it also seems to be present have suggested a central role for prefrontal-striatal net- in unaffected relatives 21 22. Furthermore, hyperactive per- works and SMA networks in OCD, with detected abnormalities in their functional connectivity and cortical ex- formance monitoring, a well-replicated finding in OCD citability. Therefore, a growing number of treatment and research (measured by error-related negativity (ERN) in functional studies have focused on modulation of these the event-related potential), is correlated to SMA hyper- circuitries, targeting specific key nodes. activity in OCD patients 12. rTMS targeting the pre-SMA, deep TMS targeting the orbi- A recent meta-analysis concluded that rTMS seems to tofrontal cortex OFC and DBS targeting the Nacc and VC/ be efficacious in the treatment of resistant OCD 7 and VS seem to be the most effective stimulation protocols in low-frequency protocols targeting the pre-SMA seem to improving OC symptoms and restoring dysfunctional pre- be the most promising interventions 7, even compared frontal-striatal and pre-motor circuitries. The effects of tDCS to usual augmentation with neuroleptic agents 3. One on OC symptoms have been less investigated, and most evi- open-label and two randomised, sham-controlled studies dence is from case reports. Nevertheless, promising results investigating the effects of low-frequency rTMS over the have been shown for cathodal stimulation of the OFC, while SMA have shown its efficacy in treatment-resistant OCD stimulation of DLPFC failed to improve symptomatology. patients 23-25. Moreover, Mantovani et al. found that clini- Further research is needed to clarify the exact mechanism cal improvement seems to be correlated to the inhibitor of action of this network-targeted treatment approach. effect of low-frequency rTMS on cortical excitability 26. A recent study has also investigated the effects of inhibitory Conflict of interests (cathodal) tDCS over the pre-SMA 27 in OCD. D’Urso et None. al. observed differential effects of excitatory (anodal) and inhibitory (cathodal) stimulation of the pre-SMA. After 10 sessions of cathodal tDCS, dramatic clinical improvement References (overall 30 % reduction in baseline symptoms severity 1 Insel T, Cuthbert B. Research Domain Criteria (RDoC): to- score on the Y-BOCS) was observed, whereas 10 sessions ward a new classification framework for research on mental of anodal tDCS led to worsening of OCD symptoms. These disorders. Am J Psychiatry 2010;167:748-51. results support the hypothesis that pre-SMA hyperfunc- 2 Insel TR. The NIMH Research Domain Criteria (RDoC) tion might be responsible for OCD symptoms and, conse- Project: precision medicine for psychiatry. Am J Psychiatry quently, that inhibitory stimulation of this region might be 2014;171:395-7. an effective new treatment strategy (ibidem). 3 Pallanti S, Marras A, Grassi, G. Outcomes with neuromodu- Interestingly, a recent case study 28 investigated the effects lation in obsessive-compulsive disorder. Psychiatric Annals of integrated low-frequency (1 Hz) rTMS of the pre-SMA 2015;45:316.

264 Can we modulate obsessive-compulsive networks with neuromodulation?

4 Rosa MA, Lisanby SH. Somatic treatments for mood disor- 18 Volpato C, Piccione F, Cavinato M, et al. Modulation of af- ders. Neuropsychopharmacology 2011;37:102-16. fective symptoms and resting state activity by brain stimu- 5 George MS, Post RM. Daily left prefrontal repetitive tran- lation in a treatment-resistant case of obsessive-compulsive scranial magnetic stimulation for acute treatment of medica- disorder. Neurocase 2013;19:360-70. tion-resistant depression. Am J Psychiatry 2011;168:356-64. 19 Ruffini C, Locatelli M, Lucca A, et al. Augmentation effect of 6 Nitsche MA, Cohen LG, Wassermann EM, et al. Transcranial repetitive transcranial magnetic stimulation over the orbito- direct current stimulation: state of the art 2008. Brain Stimu- frontal cortex in drug-resistant obsessive-compulsive disor- lation 2008;1:206-23. der patients: a controlled investigation. Prim Care Compan- ion J Clin Psychiatry 2009;11:226. 7 Berlim MT, Neufeld NH, Van den Eynde F. Repetitive 20 transcranial magnetic stimulation (rTMS) for obsessive- Mondino M, Haesebaert F, Poulet E, et al. Efficacy of cath- compulsive disorder (OCD): an exploratory meta-analysis odal transcranial direct current stimulation over the left or- of randomized and sham-controlled trials. J Psychiatr Res bitofrontal cortex in a patient with treatment-resistant obses- 2013;47:999-1006. sive-compulsive disorder. J ECT 2015 [Epub ahead of print]. 21 8 Menzies L, Chamberlain SR, Laird AR, et al. Integrating evi- Robbins TW, Gillan CM, Smith DG, et al. Neurocognitive endophenotypes of impulsivity and compulsivity: towards dence from neuroimaging and neuropsychological studies dimensional psychiatry. Trends Cogn Sci 2012;16:81-91. of obsessive-compulsive disorder: the orbitofronto-striatal model revisited. Neurosci Biobehav Rev 2008;32:525-49. 22 Fineberg NA, Potenza MN, Chamberlain SR, et al. Probing compulsive and impulsive behaviors, from animal models to 9 Figee M, Vink M, de Geus F, et al. Dysunctional reward endophenotypes: a narrative review. Neuropsychopharma- circuitry in obsessive-compulsive disorder. Biol Psychiatry cology 2010;35:591-604. 2011;69:867-74. 24 Mantovani A, Simpson HB, Fallon BA, et al. Randomized sh- 10 Pallanti S, Hollander E. Pharmacological, experimental thera- am-controlled trial of repetitive transcranial magnetic stimu- peutic, and transcranial magnetic stimulation treatments for lation in treatment-resistant obsessive-compulsive disorder. compulsivity and impulsivity. CNS Spectr 2013;19:50-61. Int J Neuropsychopharmacol 2010;13:217-27. 11 de Wit SJ, de Vries FE, van der Werf YD, et al. Presupplemen- 23 Mantovani A, Lisanby SH, Pieraccini F, et al. Repetitive tran- tary motor area hyperactivity during response inhibition: a scranial magnetic stimulation (rTMS) in the treatment of ob- candidate endophenotype of obsessive-compulsive disor- sessive-compulsive disorder (OCD) and Tourette’s syndrome der. Am J Psychiatry 2012;169:1100-8. (TS). Int J Neuropsychopharmacology 2006;9:95-100. 12 Grützmann R, Endrass T, Kaufmann C, et al. Presupplemen- 25 Gomes PVO, Brasil-Neto JP, Allam N, et al. A randomized, tary motor area contributes to altered error monitoring in double-blind trial of repetitive transcranial magnetic stimula- obsessive-compulsive disorder. Biol Psychiatry 2014 doi: tion in obsessive-compulsive disorder with three-month fol- 10.1016/j.biopsych.2014.12.010. low-up. J Neuropsychiatry Clin Neurosci 2012;24:437-63. 13 Altered corticos- Harrison BJ, Soriano-Mas C, Pujol J, et al. 26 Mantovani A, Rossi S, Bassi BD, et al. Modulation of motor triatal functional connectivity in obsessive-compulsive disor- cortex excitability in obsessive-compulsive disorder: an ex- der. Arch Gen Psychiatry 2009;66:1189-200. ploratory study on the relations of neurophysiology measures 14 Sakai Y, Narumoto J, Nishida S, et al. Corticostriatal func- with clinical outcome. Psychiatry Res 2013;210:1026-32. tional connectivity in non-medicated patients with obses- 27 D’Urso G, Brunoni AR, Anastasia A, et al. Polarity-dependent

sive-compulsive disorder. Eur Psychiatry 2011;26:463-9. effects of transcranial direct current stimulation in obsessive- 15 Ahmari SE, Spellman T, Douglass NL, et al. Repeated corti- compulsive disorder. Neurocase 2015 [Epub ahead of print]. co-striatal stimulation generates persistent OCD-like behav- 28 Adams TG Jr, Badran BW, George MS. Integration of cor- ior. Science 2013;340:1234-9. tical brain stimulation and exposure and response preven- 16 Abe Y, Sakai Y, Nishida S, et al. Hyper-influence of the orbi- tion for obsessive-compulsive disorder (OCD). Brain Stimul tofrontal cortex over the ventral striatum in obsessive-com- 2014;7:764-5. pulsive disorder. Eur Neuropsychopharm 2015; in press. 29 Grassi G, Godini L, Grippo A, et al. Enhancing cognitive- 17 Figee M, Luigjes J, Smolders R, et al. Deep brain stimulation behavioral therapy with repetitive transcranial magnetic restores frontostriatal network activity in obsessive-compul- stimulation in refractory obsessive-compulsive-disorder: a sive disorder. Nat Neurosci 2013;16:386-7. case report. Brain Stimul 2015;8:160-1.

265 Original article

O. Benzoni1, G. Fàzzari1, C. Marangoni2, A. Placentino1, A. Rossi3 1 U.O. Psichiatria 23, Azienda Ospedaliera Universitaria Spedali Civili di Brescia, Ospedale di Montichiari, Brescia, Italia; 2 Dipartimento di Scienze Biomediche e Chirurgico Specialistiche, Università di Ferrara, Italia; 3 Dipartimento di Scienze Cliniche Applicate e Biotecnologiche, Università dell’Aquila

Summary Clinical Global Improvement scale (CGI). Suicidal ideation was evaluated clinically at each follow-up visit. Objectives Electroconvulsive therapy (ECT) is a non-pharmacological treat- Results ment whose effectiveness has been demonstrated for patients Clinical evaluations made one week after ECT showed clinical suffering from severe and resistant depression, bipolar disorder improvement in 100% of patients with manic episodes, 92% and schizophrenia. Several studies demonstrated the efficacy with bipolar depression, 91% with major depression, 90% with of ECT in different subgroups, such as patients with bipolar de- schizoaffective disorder, 82% with mixed episode and 62.5% pression, mixed state, psychotic features and suicidal ideation. with catatonic features. The same evaluation repeated 6 months Herein we report a case series of 264 patients with mood and and 1 year after the ECT reaffirmed global clinical improvement schizoaffective disorders who were resistant to multiple phar- in 100% of manic patients, 88.5 with bipolar depression, 88% macological trials and treated with ECT to achieve a clinical im- with mixed episode, 83.5% with major depression, 77% with provement or remission. schizoaffective disorder and 75% with catatonia.

Methods Conclusions Patients underwent ECT at the psychiatric unit of Montichiari ECT appears to be effective in providing overall clinical improve- Hospital. All subjects had at least 18 years of age and met DSM- ment. These conclusions are, however, limited by the experimen- IV TR criteria for major depressive disorder (n = 89, 33.7%), tal design and therefore liable to many uncontrolled variables. bipolar disorder (manic n = 5, 1.89%; mixed n = 17, 6.4%; de- pressed n = 92, 34.85%), mood disorder with catatonic features Keywords (n = 8, 3.03%) or schizoaffective disorder (n = 50, 18.94%). Patients were evaluated before treatment (T0) and at one week Electroconvulsive therapy (ECT) • Treatment resistant depression • Bi- (T1), 6 months (T2) and 1 year (T3) after treatment with the polar disorder • Schizoaffective disorder • Global clinical improvement

Introduction the number of manic, hypomanic or mixed episodes 2. The most important staging protocols for the assessment Treatment resistance is a highly discussed topic in psychi- of treatment resistance in major depressive disorder are atric clinical practice, especially in the case of mood dis- those of Thase and Rush 3, Souery 4 and the Massachus- orders. In the STAR*D (Sequenced Treatment Alternatives setts General Hospital 5. Thase and Rush’s classification to Relieve Depression) study, only 67% of patients com- consists of five stages of increasing resistance to antide- pletely responded to antidepressant treatment; the rate of pressant medications up to electroconvulsive therapy response decreased at any further treatment (from 37% at (ECT), without considering dosage/duration of antidepres- the first antidepressant trial to 13% at the last trial) 1. sant trial or combinations/potentiation strategies. Souery’s Regarding to bipolar disorder, the STEP-BD (Systematic staging model identifies three stages of treatment resist- Treatment Enhancement Program for Bipolar Disorder) ance; stage one consists of cases that did not respond to a study reported that 58% of patients achieved remission in full trial of antidepressant medications (including a trial of 2 years follow-up; in this group of patients, nearly 50% had bilateral ECT) of at least 6-8 weeks of duration; stage two recurrences of illness, with depressive episodes doubling (treatment resistant depression) includes cases with resist-

Correspondence Giuseppe Fazzari, U.O. Psichiatria 23, Ospedale di Montichiari, via Giuseppe Ciotti 154, Montichiari (BS), Italia • Tel. 0309963227 • Fax 0309963214 • E-mail: [email protected]

266 Journal of Psychopathology 2015;21:266-268 Treatment of resistant mood and schizoaffective disorders with electroconvulsive therapy: a case series of 264 patients

ance to at least two trials of antidepressant medications applying LART (Left Anterior Right Temporal), reserving of different pharmacological groups; stage three (chronic the bitemporal placement for cases with florid psychotic resistant depression) includes cases with resistance to dif- symptoms or problems to the convulsion. Patients were ferent antidepressant trail, including potentiation strate- ventilated with 100% oxygen until resumption of sponta- gies, for at least 12 months of trial duration. neous respiration. The Massachusetts General Hospital classification con- The monitoring of vital signs included pulse oximetry siders both the number of failed antidepressant trials and and electrocardiogram. The stimulation parameters were: potentiation/combination strategies, without any hierar- wave width 0.30 mA, frequency 20 Hz, duration of the chy of antidepressants, creating a continuous variable stimulus 4 sec, if the seizure was not satisfactory, the du- that reflects the degree of treatment resistance. ration of the stimulus was increased to 8 sec. There are no staging protocols for assessment of treat- The number of sessions of ECT for each patient was de- ment resistance in bipolar disorder. An operationalised cided by the treating physician based on clinical observa- definition of treatment resistance should consider non- tion and course of disease. response to at least two different trials of medications Regarding concomitant therapies, anticonvulsants and approved for bipolar disorder, adequate for dosage and benzodiazepines were suspended during the sessions of duration (at least six weeks for mania, 12 weeks for de- ECT and re-administered after treatment; lithium plasma pression, 12 or more months for maintenance therapy), levels were maintained at less than or equal to 0.4 mEq/L excluding patients who responded to treatment but dis- in the days immediately preceding session of ECT and continued because of side effects 6. during the course of treatment. According to the American Psychiatric Association Task In case of resistant convulsion, we used the following op- Force on ECT 7, primary clinical indications for ECT are: tions: change anaesthetic to etomidate; use of low dose major depressive episode (both unipolar and bipolar), pro-convulsant drugs (bupropion, clozapine, mapro- manic/mixed episode, acute psychotic relapse in schizo- tiline); laryngeal mask. phrenia, schizophreniform disorder and schizoaffective disorder. Results

Materials and methods The group was composed of 264 patients (110 men) with a mean age ± SD of 51.06 ± 16.89 years for men and The initial sample consisted of 287 patients treated with 51.38 ± 13.9 for women. The mean duration of disease ECT at the psychiatric ward of the Montichiari Hospital prior to ECT was 13.5 ± 11.7 years. The distribution of between January 2005 and July 2012. All subjects were patients was: at least 18 years old; diagnosis was assessed with clinical • 92 (34.85%) bipolar disorder type I and II, major de- interview by two experienced psychiatrists (O.B and G.F.) pressive episode; according to DSM IV-TR criteria. • 89 (33.7%) recurrent major depressive disorder; All subjects did not respond to at least three different • 50 (18.94%) schizoaffective disorder (major depres- pharmacological treatments in the last six months. All sive episode); subjects gave written informed consent to ECT treatment. • 17 (6.4%) bipolar disorder type I, mixed episode; Patients were evaluated with CGI (Clinical Global Im- • 8 (3.03%) mood disorder with catatonic features; pression) scale at the beginning of the treatment (T0), and • 5 (1.89%) bipolar disorder type I, manic episode. after one week (T1), six months (T2) and 12 months (T3); At T1 follow-up, ECT treatment produced a clinical we defined response to ECT as a CGI score of 2 (moder- improvement in 100% of patients with bipolar manic ately improved) or 1 (very improved). Suicidal ideation episode, 92% of patients with bipolar major depressive was assessed clinically at every follow-up visit. episode, 91% of patients with major depressive disorder From the initial sample we excluded 23 subjects: 15 and 90% of patients with major depression in schizoaf- withdrew consent to undergo ECT; 1 had a cardiac com- fective disorder; lower percentages were found in bi- plication; 7 were lost to follow-up. polar mixed episodes (82%) and mood disorders with Procedure for ECT: anaesthesia was induced using thio- catatonic features (62.5%). pental sodium (2 mg/kg) or etomidate (0.30 mg/kg), suc- At T2 and T3 follow-up times, patients with major de- cinylcholine was used as a relaxing neuromuscular (0.5-1 pressive episodes did not maintain the level of clinical mg/kg); patients were pre-medicated with 0.5 mg atro- improvement achieved at T1 (at T2: bipolar depression pine to reduce bronchial secretions. 90%, major depression 84%, schizoaffective disorder ECT was administered using a brief pulse stimulator 80%; at T3: bipolar depression 87%, major depres- Mecta 5000Q, three times a week. The electrode place- sion 83%, schizoaffective disorder 74%), while manic, ment was bitemporal until February 2009, subsequently mixed and catatonic patients performed far better (at T2

267 O. Benzoni et al.

and T3: bipolar manic 100%, bipolar mixed 88%, cata- cally; 5) co-morbidity with other psychiatric disorders tonic 75%). and with substance abuse/addiction was not evaluated; Regarding the presence of suicidal ideation, 53% of pa- 6) the patients’ diagnostic distribution is asymmetric, and tients with bipolar major depression, 37.5% of patients so it is difficult to make meaningful comparisons between with catatonic features, 36% of patients with major de- responses to ECT. pressive disorder, 29% of patients with bipolar mixed episode, 22% of patients with schizoaffective disorder Conflict of interests and 20% of those with bipolar manic episode presented None. suicidal ideation at the baseline evaluation pre-ECT (T0). In subsequent follow-up (T1-T2-T3), patients with bipolar References manic and mixed episode and those with catatonic fea- 1 Rush AJ. STAR*D: what have we learned? Am J Psychiatry tures no longer had the presence of suicidal ideation; a 2007;164:201-4. sharp reduction in suicidal ideation was also detected in 2 other disorders (ranking bipolar major depression> uni- Perlis RH, Ostacher MJ, Patel JK, et al. Predictors of recur- rence in bipolar disorder: primary outcomes from the Sys- polar major depression > schizoaffective disorder); two tematic Treatment Enhancement Program for Bipolar Disor- suicides occurred at T2 (1 patient with major depressive der (STEP-BD). Am J Psychiatry 2006;163:217-24. disorder, 1 patient with schizoaffective disorder). 3 Thase ME, Rush AJ. When at first you don’t succeed: se- quential strategies for antidepressant nonresponders. J Clin Discussion Psychiatry 1997;58(Suppl 13):23-9. 4 Souery D, Amsterdam J, de Montigny C, et al. Treatment In our sample, ECT was found to produce a rapid clinical resistant depression: methodological overview and opera- improvement in patients with treatment resistant bipolar tional criteria. Eur Neuropsychopharmacol 1999;9:83-91. mania, bipolar and unipolar major depression and schiz- 5 Fava M. Diagnosis and definition of treatment resistant de- oaffective disorder. These findings are consistent with pression. Biol Psychiatry 2003;53:649-59. those reported in the literature 8-10. We found a progres- 6 Poon SH, Sim K, Sum MY, et al. Evidence-based options for sive reduction in clinical improvement in patients with a treatment-resistant adult bipolar disorder patients. Bipolar major depressive episode: this can be explained by the Disord 2012;14:573-84. fact that ECT has a rapid antidepressant response and a 7 American Psychiatric Association, Committee on Electro- mood stabilising effect over time. convulsive Therapy. The practice of electroconvulsive ther- Our data also confirm the effectiveness of ECT in reliev- apy: recommendations for treatment, training, and privileg- 11 ing suicidal ideation . Patients with mania, mixed epi- ing. 2nd ed. Washington, DC: American Psychiatric Publish- sode and catatonia had the best response to ECT in terms ing 2001. of antisuicidal effects, which were maintained through- 8 Kellner CH, Greenberg RM, Murrough JW, et al. ECT out follow-up. The rate of suicide in our sample of patient in treatment-resistant depression. Am J Psychiatry treated with ECT was 0.75%, which is well below the rate 2012;169:1238-44. 11 of untreated severe mood and psychotic disorders . 9 Dierckx B, Heijnen WT, van den Broek WW, et al. Efficacy This study has several limitations: 1) the observational of electroconvulsive therapy in bipolar versus unipolar major design of the study is subject to many uncontrolled vari- depression: a meta-analysis. Bipolar Disord 2012;14:146-50. ables; 2) treatment resistance was defined widely and 10 Pompili M, Lester D, Dominici G, et al. Indications for elec- we did not report information regarding pharmacologi- troconvulsive treatment in schizophrenia: a systematic re- cal treatment before ECT; 3) the outcomes after ECT were view. Schizophr Res 2013;146:1-9. evaluated only with the CGI scale and not with other val- 11 Fink M, Kellner CH, McCall WV. The role of ECT in suicide id rating scales; 4) suicidal ideation was evaluated clini- prevention. J ECT 2014;30:5-9.

268 Original article

M. Ferrara 1, F. Mungai 1, M. Miselli 1, D. Shiers 2, J. Curtis 3 4, F. Starace 1 1 Department of Mental Health and Substance Abuse, AUSL Modena, Modena, Italy; 2 Retired General Practictioner, Leek, North Staffordshire, UK; 3 School of Psychiatry, University of New South Wales, Sydney, Australia; 4 Early Psychosis Programme, The Bondi Centre, South Eastern Sydney Local Health District, Sydney, Australia

Summary utilised varied across studies and was mediated by a broad range of barriers. Nevertheless, some studies showed that the introduc- Objectives tion of a systematic approach can improve the monitoring by up To review the strategies implemented in clinical practice to in- to 100%. crease monitoring and active interventions to reduce cardiovascular risk in individuals with severe mental illness and their pos- Conclusions sible implementation in first episode psychosis (FEP) care. Despite heightened risk of developing cardiovascular and metabolic disorders, systematic monitoring of physical health is often Methods suboptimal and haphazard. There is a paucity of specific proto- A PubMed literature search was performed using the following cols for people with FEP. Results seem more promising when the key words: “metabolic syndrome”, “antipsychotic”, “schizophre- approach to physical health is multidisciplinary and integrated nia”, “psychosis”, “severe mental illness”, “intervention”, “obe- with primary care. In this regard, a computerized version of the sity”, “weight”, “physical health” and a combination of all above. Australian Positive Cardiometabolic Health Algorithm, along with a health check list completed by psychiatric nurses, seems Additional papers were identified through references and based to be the basis to improve monitoring and effective interventions on expert consultation as necessary. aimed at preventing cardiovascular events in individuals suffering from FEP. Results The review identified 14 studies in which a variety of different Key words monitoring instruments were adopted in a range of clinical settings. Only three studies were carried out in subjects affected by Cardiovascular disease • Early intervention • Metabolic syndrome • FEP. The degree to which systematic monitoring was successfully Obesity • Psychotic disorders

Introduction ond generation antipsychotic (SGA) class appear more likely to affect the metabolic profile (e.g. clozapine and Compared to the general population, people affected by olanzapine) 11. A matter of concern is represented by schizophrenia have up to 20% shorter life expectancy, the fact that SGAs are usually preferred over typical an- with cardiovascular disease representing the leading tipsychotics in individuals affected by first episode psy- cause of death, occurring at a rate that is 10-fold higher chosis (FEP) 12 13, despite a higher incidence of weight 1-6 than suicide . Factors contributing to the overall poor- gain and metabolic side effects compared to the majority er health are those associated with lifestyle, such as an of first generation antipsychotics 9. A large number of unhealthy diet, lack of exercise and high rates of smok- studies have reported high rates of metabolic syndrome ing 7 8. While the distinction between first and second among patients treated with SGAs; prevalence rates are generation antipsychotics is becoming more controver- over 50% for pre-diabetes or type II diabetes in adult sial 9 10, some drugs described as belonging to the sec- psychiatric inpatient populations 14. Moreover, younger

Correspondence Maria Ferrara, Department of Mental Health and Substance Abuse, AUSL Modena, viale Muratori 201, 41124 Modena, Italy • Tel. +39 059 435970 • Fax +39 059 435800 • E-mail: [email protected]

Journal of Psychopathology 2015;21:269-280 269 M. Ferrara et al.

individuals appear to be at higher risk than adults for Methods developing weight gain and metabolic abnormalities related to antipsychotic treatment 14-17. An average weight A thorough literature search was performed on Pub- gain of 12 kg has been reported in patients with severe Med and Internet databases to identify articles deal- mental illness (SMI) within 24 months of their first psy- ing with strategies, adopted by different mental health chotic episode and subsequent treatment 18. In addi- providers worldwide, to implement monitoring and tion, as many as 9% of SMI patients are at high risk of intervention for physical health in SMI. Words used, cardiovascular disease (CVD) within 12 months of their in varying combinations, were “metabolic syndrome”, FEP, due to their vulnerability to weight gain and meta- “antipsychotic”, “schizophrenia”, “psychosis”, “severe bolic dysfunction 18-20. These alarming data clearly em- mental illness”, “intervention”, “obesity”, “weight”, phasise the importance of close monitoring of physical “physical health”, “cardiovascular”. Further references health in patients enrolled in FEP programs undergoing were extracted from selected articles based on authors’ antipsychotic treatment. In response to these concerns, choices. Articles were excluded when full text was not several management guidelines and quality standards available. have been published in recent years 21-40. However, the evidence suggests that the availability of guidelines and Results standards does not always translate into their implemen- A total number of 128 articles were identified; of 114 tation in routine clinical practice 41. papers excluded, 47 reported efficacy of specific inter- The aim of this paper is to provide an overview of the ventions, both pharmacological as non-pharmacological, most recent literature on strategies implemented in rather than strategies to implement such intervention in clinical practice to increase monitoring and active in- routine care and therefore were not included in the cur- terventions to reduce cardiovascular risk in individuals rent review, as shown in Figure 1. A total of 14 articles suffering from severe mental illness and their possible were finally selected, as reported in Table I. implementation in care of first episode psychosis (FEP). Among the 14 articles identified, only three focused on The Italian adaptation of the Positive Cardiometabolic people at first episode of psychosis (FEP), while 11 ad- Health Algorithm. dressed the problem in people affected by a severe mental illness (SMI).

The Italian adaptation of the Positive Cardiometabolic Health Algorithm

114 references excluded:

• 17 surveys, focus groups, meetings reports • 11 epidemiological studies 2 references added • 41 non-pharmacological interventions (author’s choices) • 6 pharmacological interventions • 39 review papers

14 references included

Figure 1. Results. Risultati.

270 Strategies to implement physical health monitoring in people affected by severe mental illness: a literature review and introduction to the Italian version of the Positive Cardiometabolic Health Algorithm

Table I. Studies included in current review. Studi selezionati ai fini della revisione della letteratura.

First Author Year Country Population studied Method/methods applied Results Bressington 2014 Hong 148 community-based pa- A consecutive prospective HIP** was feasible and use- Kong tients with severe mental ill- case series design. HIP** was ful, 93% applied at baseline. ness, Hong Kong population. used as a screening tool at No statistical improvement in baseline and repeated at 12 relation to health behaviours months follow-up adopted by patients and indicators of vascular disease. Curtis 2012 Australia FEP† patients attending Bondi Multidisciplinary approach NA‡ Service using the paper sheet Positive Cardiometabolic Algorithm as framework. DelMonte 2012 USA Psychiatric inpatient unit. Pop-up alert for ordering lipid Significantly improved rates of 171 and 157 patients taking and glucose checking. ordering fasting blood glucose SGAs §, respectively in the and lipid levels. Significantly pre-alert group, and post alert more post-alert laboratory orders group. were submitted at the same time as the SGA§, drug order. Overall rates remained suboptimal Gonzalez 2010 UK Community mental health Audit, 3 meetings with local Significant improvement in Center. 126 patients pre-au- consultants, 2 brief educa- the performance of each test, dit, 106 post-audit, all treated tional talks to junior doctors, except for glycated haemo- with antipsychotics. single page monitoring tool globin and prolactin. sheet implemented. Hardy 2012 UK 29 patients with SMI*. To examine patients’ views All of the patients reported about the physical health check that they had started to make delivered by a nurse trained in changes to their lifestyle since the Northampton Physical He- the health check. alth and Wellbeing project Hardy 2012 UK 92 Psychiatric patients and Invitation appointment letter 66% of SMI* vs. 81% diabe- 416 diabetic patients to attend a physical health tic patients attended the prac- check in primary care. Com- tice on the date stipulated in parison with patients affected the letter. by diabetes. Rosenbaum 2014 Australia 60 users, inpatient psychiatric Audit, educational training, Improved monitoring of waist unit. including waist circumferen- circumference from 0 to 58% ce measurement in the paper- sheet monitoring form. Shuel 2010 UK 31 community patients with Qualitative evaluation of a Qualitative feedback on the SMI* paper-sheet screening in- instrument was positive. 28 strument implemented: the discreet interventions were serious mental illness health used. improvement profile. Thompson 2011 Australia Patients with FEP† taking an- Audit, analysis of barriers, Significant improvements in both tipsychotics: 119 in the pre- provision of monitoring the screening and the monitoring intervention audit, 86 in the equipment, interactive edu- of metabolic indices following post-intervention audit. cational events, reminders initiation of antipsychotic medi- and prompts. cations. Improvements in the number of active interventions offered. Level of guideline concor- dant monitoring remained low.

(continues)

271 M. Ferrara et al.

Table I - Follows

First author Year Country Population studied Method/methods applied Results Vasudev 2010 UK 15-bed male medium secure Audit cycle completed in 1 Monitoring sheet adopted in forensic psychiatric rehabili- year. Physical health monito- 100% charts. Serum lipid and tation unit. ring sheet introduced in the cardiovascular risk reduced. patients record. Vasudev 2010 UK Patients with SMI* under the Audit: evaluate physical he- The number of patients un- care of early intervention psy- alth monitoring practices and dergoing at least one annual chosis service: 66 FEP† at ba- Re-Audit. Letter to the general physical health check in- seline, 76 at re-audit. pratictioner for inviting pa- creased from 20% to 58%. tients taking a physical exam and lab tests. White 2011 UK Adult patients with a Protocol: single blind parallel NA ‡ SMI*diagnosis. group randomised controlled trial with secondary economic analysis and process observation. To determine the effects of the HIP** programme on patient's wellbeing. Wiechers 2012 USA 206 adult patients of a psy- Quality improvement inter- Rates of screening single me- chiatric resident outpatient vention: focus group, resident tabolic item increased betwe- clinic education, and metabolic en 3.5 to 10 fold. Screening screening bundle for electro- for the full metabolic bundle nic devices. increased 30 fold. Wilson 2014 Australia Physical health month Audit, scheduled monitoring Monitoring of physical health (PHM)1: 224 users taking 6 months apart, lessons by improved from 0 to 68%. In- clozapine. PHM2: 232 users physicians, overseen weekly. terventions did not increase. taking clozapine. Abbreviations: *SMI: Severe Mental Illness; † FEP: First Episode Psychosis; ‡ NA: Not available; § SGAs: Second Generation Antipsychotics; **HIP: Health Im- provement Profile

Strategies to improve physical health monitoring a registry of people with SMI and checked their physical in FEP health annually 46; this reward measure might have signifi- Among the three papers dealing with strategies to improve cantly contributed to the positive result of the audit. A year later Thompson et al. 42 carried out a study on measures to physical health monitoring in FEP, two reported on studies improve levels of screening and management of physical performed in Australia 42 43 and one in the UK 44; the aim health within a FEP service in Australia. An analysis of pos- was to adapt current guidelines to the stricter population sible barriers and enablers, availability of local guidelines, of people affected by FEP. In order to overcome barriers to educational interventions, service changes, and provision implementation of the UK NICE guidelines 45 on monitor- of monitoring equipment preceded the study. Despite a 46 ing physical health in FEP, Vasudev et al, carried out an significant improvement in both overall screening and ini- audit. Actions implemented were: a) mandatory letters to tial monitoring of metabolic indicators in people enrolled general practitioners (GPs) emphasising the importance of in FEP services, rates of clinical management of physical physical tests, and b) a nurse-led support for patients to health was still far from guidelines standards, underlying book two appointments with their GP (one for prescrip- again the demand for more ‘creative’ strategies addressing tion of laboratory tests and physical examination, one specific needs of young people affected by FEP, such as, for discussing results). A significant increase (from 20% ‘headspace’ initiatives. In the field of FEP, ‘The Bondi Early to 58% screened) in the rates of physical health check Psychosis Programme’ targets young people (aged 15–25 performed in FEP patients was documented. Authors un- years) experiencing their first episode of psychosis with derlined that within the same period of time a Quality the ‘Keeping the Body in Mind Programme’ lifestyle inter- Outcome Framework (QOF) of the general medical ser- vention as part of standard care 43. The Bondi Service has vices agreed to financially reward GPs who maintained developed a model of metabolic screening and a treat-

272 Strategies to implement physical health monitoring in people affected by severe mental illness: a literature review and introduction to the Italian version of the Positive Cardiometabolic Health Algorithm

ment algorithm called “Positive Cardiometabolic Health” monitoring physical health is not a necessary task and is to provide clinicians with recommendations for early de- not responsibility of psychiatric nurses. Offering educa- tection, prevention and intervention strategies targeting tion in this area will improve patient outcomes through a antipsychotic-induced metabolic abnormalities and car- direct and/or indirect change in nurse attitude, knowledge diovascular risk factors 43. and behaviours 41 51. The same group subsequently developed a training package for practice nurses (PhyHWell) Strategies to improve physical health monitoring that was shown to be effective in modifying misconcep- in subjects with SMI tions regarding physical health in people with SMI 51. In the context of community mental health services, the A screening instrument, called Heath Improvement Pro- strategies adopted to assess the level of awareness to- file (HIP), first developed and implemented by Shuel in 52 53 wards cardiometabolic risk in subjects with SMI have 2010 was adopted by Bressington et al. in a com- been mostly audits. munity outpatient sample in Hong Kong. HIP is a 27-item In 2010, Gonzalez et al. 47 performed an audit to im- screening and change tool that directs nurses and pa- prove physical health assessment in outpatient clinics: it tients to select interventions to improve physical health. The implementation was found to be feasible and useful included a review of medication charts and patient notes, to identify areas where physical health requires interven- 3 meeting with the local consultants and two brief edu- tion. To test which instruments were more effective in cational talks, plus the introduction of a paper monitor- improving physical wellbeing in patients with SMI than ing sheet. A significant improvement was reported in the those in current practice, White et al. designed a single overall performance of many laboratory tests, for exam- blind parallel group cluster RCT; however, the results ple, glucose test prescription increased from 24.6% to have not yet been published 54. Vasudev et al. 55 intro- 72.6%; however, the screening was still suboptimal and duced a single A4 physical health monitoring sheet in did not include anthropometric measures (waist circum- the chart of patients of a 15 bed male medium secure ference-WC, body mass index-BMI, blood pressure-BP, forensic psychiatric rehabilitation unit. Nurses and junior ECG monitoring). doctors completed this chart every 6 months. After one Hardy et al. 48 performed an audit to promote attendance year, re-audit showed that 100% of the patient records of patients suffering from SMI to GPs for an annual physi- reported up-to-date information on monitoring sheets. cal health check; a letter offering an appointment with a Moreover, it was observed that the introduction of the predetermined date and time at the GP office was sent to monitoring sheet prompted the prescription of hypolipi- patients. Up to 70% patients with SMI attended their GP daemic drugs. Rosenbaum 56 included waist circumfer- surgeries for a health check. ence as a routine measure to assess during admission to 49 Wiechers created a quality improvement intervention a psychiatric inpatient unit. An audit based on psychiat- in an academic hospital psychiatric outpatient clinic to ric nurses practice was performed thereafter. The authors improve rates of metabolic screening in patients receiv- provided 20 min of educational training and created a ing antipsychotics. The core components of the interven- blank space slot for the registration of waist circumfer- tion were focus groups, resident education and creation ence (WC) measurement in the patient file completed by of a metabolic screening bundle template in electronic nurses at admission. This economic and relatively sim- medical records, in addition to a focus group mid-way ple intervention led to an increase of WC measurement along the intervention to identify ongoing barriers to the and recording from 0% to 58% within 12 weeks, with a intervention itself. The documentation increased from ‘persisting’ effect on clinical practice even after 9 months 1% to 31% of the full metabolic screening bundle, with from the time of the educational intervention. blood pressure measure resulting the least documented Finally, work on the implementation of metabolic index in charts. More recently, Wilson 50 carried out an screening pop-up alert in the computerised physician audit focused on patients taking clozapine. He reported order entry system was carried out by DelMonte et al. a suboptimal rate of health check monitoring; thus, he for people taking SGAs after the admission to a 22 bed scheduled two monitoring visits 6 months apart for pa- general psychiatric unit 57. Despite this, implementa- tients on clozapine during two “physical health months”. tion was quite successful (for instance the availability Unfortunately, the increased level of physical health of data regarding fasting glucose and lipid levels in- monitoring did not automatically translate into an ap- creased from 12.9% to 47.8%), but overall physical propriate documented intervention: in fact, only 30% of health monitoring remained suboptimal and incom- patients with metabolic syndrome were followed. plete: in fact, the pop-up alert takes into account only Accordingly to Hardy et al. 41 educational intervention two of the six monitoring parameters recommended by itself could be the object of investigation, as the lack of the 2004 ADA consensus guideline recommendations evidence based education could strengthen the idea that for people taking SGAs.

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Discussion SMI. This approach is potentially user friendly both for patients, especially younger patients who are more fa- Among many studies on the increased cardiovascular miliar with mobile apps, and for clinicians using apps or risk associated with poor physical health in people af- alarm as a mandatory reminder for scheduling lab tests or fected by SMI, only a few focus on the assessment and physical check. On the other hand, the traditional invita- intervention programs. Despite the great concern ex- tion letter adopted by two studies 44 48 highlighted poten- pressed by the scientific community regarding the need tial barriers: it was observed that the letter addressed to to monitor physical health in young people affected by a the GP was more effective when it was mandatory for the severe mental illness at the earliest, only 3 studies have nurses to send it out, coinciding with GPs being reward- been published to date on this issue i; however, strategies ed for maintaining a registry of people with SMI, a factor adopted in Mental Health Services for people affected by likely to have increased adherence to the physical health SMI can be adapted to FEP users. check by GPs. A barrier to the effectiveness of the letter There are few studies on the increased cardiovascular addressed to the patient could be related to illness fac- risk associated with poor physical health in people af- tors, such as the letter provoking undue suspicion or anxi- fected by SMI, and research to evaluate assessment and ety in the patient in response to an invitation to undergo intervention programs is needed. Despite the great con- physical examination or laboratory tests, particularly in cern expressed by the scientific community regarding the the acute phase of the illness 70. Other barriers might in- need to monitor early physical health in young people clude ease of making appointments, lack of familiarity affected by a severe mental illness, only 3 studies have with the health practitioner and delayed appointments in been published to date on this issue in FEP; however, noisy waiting areas 71 72. Moreover, younger patients may strategies adopted in Mental Health Services for people already be ambivalent to health checks 73; this observa- affected by SMI can be adapted to FEP users. tion is particularly relevant to people experiencing FEP, The majority of the studies reviewed focused on outpa- mostly adolescents and young adults between 15 and 25 tient community services, while only 3 addressed the years old, and is worthy of careful consideration by cli- problem of physical health in the context of psychiatric nicians and service planners. In this regard, a SMS and inpatient units 55-57. Inpatient admission represents a val- email reminder was found to be effective in improving uable opportunity to register baseline anthropometric adherence to treatment in young people affected by type and metabolic data since patients experiencing FEP are 1 Diabetes 74 75. still drug naïve. In fact, despite the wider availability of In five studies, a paper chart was attached to patient med- specialised community mental health services, patients ical records 43 55 53 56, improving screening for metabolic through FEP tend to have their first contact with psy- disturbances in all cases. However, data on cardiovas- chiatric service thorough emergences services (emer- cular risk factor vary substantially, remaining suboptimal gency room in the general hospital, inpatient unit, crisis in few cases 47 56 as shown in Table II. Electronic pop-ups team) 58 59, and 63% to 81% of patients with FEP require could potentially be more effective in reminding clini- hospitalisation for treatment 59-63. While some studies cians and nurses to perform a physical check. However, have shown that obesity and insulin resistance might al- they usually require time and additional funds for com- ready be present in people at FEP 34 64-68, it is also evident munity mental health services. Meanwhile, a paper sheet that these problems can accelerate rapidly after starting algorithm could be a user-friendly instrument to share antipsychotic treatment 20 68: laboratory tests performed with GPs, facilitating communication between clinicians during the initial hospital admission could be subse- and enabling them to improve their holistic approach. quently shared with community mental health profes- Prompts to patients and their families to request the ap- sionals and GPs in order to monitor and track changes plication of the algorithm is another way to reinforce ad- and to make ad hoc, individualised interventions when herence and is currently being utilised in the implemen- necessary, e.g. start hypoglycaemic medications, switch tation of the Lester UK version of the Australian Positive antipsychotics etc. Cardiometabolic Health Algorithm 43 76. The diffusion of smartphone usage offers new poten- An audit approach was adopted in 6 of 14 studies, with tials for medical applications that could help clinical the specific intention to improve the quality of care in decisions, reduce errors and increase overall quality of the outpatient services. The majority of the audits were care 69. However, only two studies implemented either supported by educational intervention targeted at mental a metabolic screening bundle template in the electronic health professionals nurses 42 50, psychiatrist residents 47 49, medical records 49 or a metabolic screening pop-up alert general practitioners 44 48, service changes and provision in the computerised physician order entry system 57. Both of monitoring equipment 42 56, but rarely scheduled super- strategies appeared feasible and effective in increasing visions 50. Despite the general opinion that educational the screening for physical health in people affected by intervention directed to specialised nurses is crucial to

274 Strategies to implement physical health monitoring in people affected by severe mental illness: a literature review and introduction to the Italian version of the Positive Cardiometabolic Health Algorithm

get positive results, no evidence has been reported 77 sup- mends that mental health services take lead responsibil- porting a correlation between that intervention and clini- ity for physical health monitoring in the first 12 months cal outcome; thus, evidence based educational interven- following initiation of antipsychotic medication, and that tions are needed to change misconceptions and attitudes lead responsibility may shift to primary care thereafter. of mental health professionals and providers to improve The algorithm developed by Curtis et al. 43 may be a use- the overall service. ful instrument in clinical practice, evidence-based and of- The majority of the studies reviewed reported strategies to fer a simple framework of what should be measured and improve metabolic screening and intervention to be per- actions to consider if problems are detected. Scaled up formed exclusively by mental health professionals, with to national level, the Lester UK Adaptation provides the only a few exceptions 41 42 44 52. This could explain, at least core monitoring instrument of a National Commissioning in part, why screening was suboptimal in the majority of for Quality and Innovation initiative to financially incen- cases and why it was rarely followed by adequate inter- tivise mental health services to improve physical health ventions, as already reported by Cahn et al. 30 and De Hert monitoring (NHSE CQUIN 2014/15 guidance). Moreo- et al. 7. Clinicians often complain of obstacles preventing ver, after reviewing all the instruments adopted in various adequate implementation of physical health checks in clinical settings, the Algorithm first published by Curtis in routine practice. These include lack of basic equipment Australia seemed the most complete regarding physical to perform physical assessments 78, poor information health data collected, as shown in Table II; it is easy to technology support for recording and sharing laboratory apply in real world settings, as shown by its implementa- investigations, being overwhelmed with emergencies in tion in Australia, UK, Canada and Japan (www.iphys.org. a time-limited consultation setting and lack of sufficient au), and designed to be shared with GPs. In considera- training or skills to provide a holistic intervention 79. An tion of the above data, an Italian adaptation of the Curtis integrated approach with general practitioners, as re- et al. Positive Cardiometabolic Health Algorithm 43 has ported by Curtis 43, Vasudev 44 and Hardy 48, could be an been produced (Appendix). Further improvements could effective strategy to overcome the above barriers and im- potentially be gained if the clinical algorithm is imple- prove routine care. However, in any integrated approach mented in an electronic format and with pop-up alerts for clinical accountability should be clear. NICE 80 recom- timely administration.

Table II. Data collected in studies reviewed regarding cardiovascular risk factors. Dati clinici riguardanti fattori di rischio cardiovascolare inclusi negli studi identificati.

First author, Year Metabolic syndrome SMOKING EXERCISE OTHER GLU LIP WC BMI BP STATUS Curtis, 2012 ✓ ✓ ✓ ✓ ✓ ✓ ✓ Polycystic ovary syndrome, lifestyle Delmonte, 2012 ✓ ✓ NA NA ✓ NA NA Weight Gonzales, 2010 ✓ NA NA NA ✓ NA NA FBC, urea, electrolytes, liver and thyroid

function, prolactin, Hb2Ac, weight Rosenbaum, NA NA ✓ ✓ ✓ ✓ NA NA 2014 Shuel, 2010 ✓ ✓ NA ✓ NA ✓ ✓ Pulse, temperature, liver function, cervical smear, diet, safe sex, sleep, dental health, breast check, testicle and prostate self examination, menstrual cycle, teeth, eyes, feet, bowels, urine, cannabis and caffeine use. Thompson, 2011 ✓ ✓ ✓ ✓ ✓ ✓ ✓ NA Vasudev, 2010 ✓ ✓ ✓ ✓ ✓ ✓ NA FBC, CV RISK, ECG, alcohol intake Wiechers, 2012 ✓ ✓ NA ✓ ✓ NA NA NA Wilson, 2014 ✓ ✓ ✓ ✓ ✓ ✓ ✓ Alcohol intake GLU: blood glucose, LIP: blood lipids (total cholesterol, LDL-cholesterol, HDL-cholesterol), WC: waist circumference, BMI: body mass index, BP: blood pressure, NA: not available, FBC: full blood count, CV: cardiovascular, ECG: electrocardiogram

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The current review has some limitations: the first is the 12/28; COMPARE programme funded by National Institute paucity of data regarding specific strategies to implement for Health Research for Patient Benefit (RfPB) programme: PB- physical health monitoring in people affected by FEP. De- PG-1112-29057. Royalties from French P, Smith J, Shiers D, spite clear evidence that cardiometabolic risk appears Reed M, Rayne M (2010) Promoting Recovery in Early psychosis Blackwell Publishing Ltd, Oxford. early and that the best predictor for long-term weight gain Membership of the current NICE quality standard group for is an increase of more than 5% after one month of psy- children and adolescents affected by bipolar disorder, psychosis 81 chopharmacological treatment , at least due in part to and schizophrenia; Board member of the National Collaborat- the direct consequence of prescribed antipsychotic medi- ing Centre for Mental Health (NCCMH); Member of the Expert cation 82, monitoring and intervention for physical health Reference group of NICE Better Access to Early Intervention for in people affected by FEP is still suboptimal and varies sig- Psychosis Services by 2020; Clinical Advisor (paid consultancy nificantly across countries. Among the reasons for the lack basis) to National Audit of Schizophrenia (NAS). These are my of systematic approach to physical health monitoring and personal views and not those of NICE, NCCMH or NAS. intervention in FEP, several factors should be considered to JC has received an unrestricted educational grant from Janssen- play a key role: the diversity of methods adopted, absence Cilag and speaker honoraria from Pfizer, Astra-Zeneca and Jans- sen-Cilag, as well as grants from NSW Health. of RCTs on this topic and lack of instruments adapted to FS has received speaker honoraria from Lundbeck, as well as a population that is often younger than average users with grants from Emilia Romagna Regional Administration. SMI, and sometimes difficult to engage in treatment 83. Alongside the above-mentioned difficulties to adapt strategies for people affected by SMI to monitor physi- References cal health in FEP, several barriers to access healthcare 1 Colton CW, Manderscheid RW. Congruencies in increased for people with a SMI have also been identified. Many mortality rates, years of potential life lost, and causes of authors reported inequalities for access in care 7 84 in peo- death among public mental health clients in eight states. ple affected by SMI. Barriers to physical health care are Prev Chronic Dis 2006;3:A42. perceived by patients and healthcare staff across all steps 2 Druss BG, Zhao L, Von Esenwein S, et al. Understanding of healthcare delivery 71, including: a) identification of excess mortality in persons with mental illness: 17-year fol- health problems 71 72 85 86, b) reaching healthcare servic- low up of a nationally representative US survey. Med Care es 72 85 87, c) financial problems 88 d) health care profes- 2011;49:599-604. sionals work overload 89 and e) follow-up to identified 3 Nordentoft M, Wahlbeck K, Hallgren J, et al. Excess mortal- physical health problem 78 85 86 89. ity, causes of death and life expectancy in 270,770 patients The small number of reported studies underlines the large with recent onset of mental disorders in Denmark, Finland gap between the spread of guidelines that reflects the and Sweden. PLoS One 2013;8:e55176. need of monitoring physical health in people affected by 4 Hennekens CH, Hennekens AR, Hollar D, et al. Schizophre- SMI, and the barriers emerging in mental health services nia and increased risks of cardiovascular disease. Am Heart to implement new strategies in clinical practice. J 2005;150:1115-21. Improving care of physical health is a pressing need for 5 Brown S. Excess mortality of schizophrenia. A meta-analy- patients affected by FEP 82. No monitoring is unethical, sis. Br J Psychiatry 1997;171:502-8. risky and then unacceptable. Effective intervention is pro- 6 Brown S, Inskip H, Barraclough B. 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276 Strategies to implement physical health monitoring in people affected by severe mental illness: a literature review and introduction to the Italian version of the Positive Cardiometabolic Health Algorithm

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73 Deeks A, Lombard C, Michelmore J, et al. The effects of gen- 83 Tindall R, Francey S, Hamilton B. Factors influencing en- der and age on health related behaviors. BMC Public Health gagement with case managers: perspectives of young peo- 2009;9:213. ple with a diagnosis of first episode psychosis. Int J Ment 74 Franklin VL, Waller A, Pagliari C, et al. A randomized con- Health Nurs 2015;24:295-303. trolled trial of Sweet Talk, a text-messaging system to support 84 Scott D, Platania-Phung CHappell B. Quality of care for car- young people with diabetes. Diabet Med 2006;23:1332-8. diovascular disease and diabetes amongst individuals with 75 Hanauer DA, Wentzell K, Laffel N, et al. Computerized Au- serious mental illness and those using antipsychotic medica- tomated Reminder Diabetes System (CARDS): e-mail and tions. J Health Qual 2012;34:15-21. SMS cell phone text messaging reminders to support diabetes management. Diabetes Technol Ther 2009;11:99-106. 85 McCabe MP, Leas L. A qualitative study of primary health 76 Shiers DE, Rafi I, Cooper SJ, Holt RIG. 2014 update (with care access, barriers and satisfaction among people with acknowledgement to the late Helen Lester for her contribu- mental illness. Psychol Health Med 2008;13:303-12. tion to the original 2012 version) Positive Cardiometabolic 86 Schmutte T, Flanagan E, Bedregal L, et al. Self-efficacy Health Resource: an intervention framework for patients and self-care: missing ingredients in health and healthcare with psychosis and schizophrenia. London: Royal College among adults with serious mental illnesses. Psychiatr Q of Psychiatrists 2014 2009;80:1-8. 77 Hardy S. Training practice nurses to improve the physical 87 Mesidor M, Gidugu V, Rogers ES, et al. A qualitative study: health of patients with severe mental illness: effects on be- barriers and facilitators to health care access for indi- liefs and attitudes. Int J Ment Health Nurs 2012;21:259-65. viduals with psychiatric disabilities. Psychiatr Rehabil J 78 Barnes TR, Paton C, Cavanagh MR, et al. A UK audit of 2011;34:285-94. screening for the metabolic side effects of antipsychotics in community patients. Schizophr Bull 2007;33:1397-403. 88 Borba CP, DePadilla L, McCarty FA, et al. A qualitative study 79 Szpakowicz MHerd A. “Medically cleared”: how well are examining the perceived barriers and facilitators to medical patients with psychiatric presentations examined by emer- healthcare services among women with a serious mental ill- gency physicians? J Emerg Med 2008;35:369-72. ness. Womens Health Issues 2012;22:e217-24. 80 NICE, The National Institute for Health and Clinical Excellence. 89 Wright CA, Osborn DP, Nazareth I, et al. Prevention of coro- Psychosis and schizophrenia in adults: treatment and manage- nary heart disease in people with severe mental illnesses: a ment. NICE CG 178, Clinical Guidelines. London 2013. qualitative study of patient and professionals’ preferences 81 Eap CB. Genetic and clinical determinants of weight gain for care. BMC Psychiatry 2006;6:16. and/or metabolic syndrome in a large psychiatric sample 90 Berenholtz SM, Milanovich S, Faircloth A, et al. Improv- treated with psychotropic drugs. American Psychiatric As- ing care for the ventilated patient. Jt Comm J Qual Saf sociation, 168th Annual Meeting, Toronto, Canada, 2015. Poster Presentation, May, 19. 2004;30:195-204. 91 82 Correll CU, Robinson DG, Schooler NR, et al. Cardiometa- Were MC, Shen C, Tierney WM, et al. Evaluation of comput- bolic risk in patients with first-episode schizophrenia spec- er-generated reminders to improve CD4 laboratory monitor- trum disorders: baseline results from the RAISE-ETP study. ing in sub-Saharan Africa: a prospective comparative study. JAMA Psychiatry 2014;71:1350-63. J Am Med Inform Assoc 2011;18:150-5.

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Appendix

280 Assessment and instruments in psychopathology

Validation of the Italian Version of the Aberrant Salience Inventory (ASI): a New Measure of Psychosis Proneness Validazione della Versione italiana dell’Aberrant Salience Inventory (ASI): una nuova misura per la vulnerabilità alla psicosi

L. Lelli1, L. Godini1, C. Lo Sauro2, F. Pietrini1, M. Spadafora1, G.A. Talamba1, A. Ballerini1

1 Department of Neuroscience, Psychology, Drug Research and Child Health. University of Florence, Italy; 2 Department of Health Sciences, University of Florence, Italy

Summary Results Patients reported a higher ASI total score than controls Objectives (p < 0.001), while the difference in ASI total score between Aberrant salience is the unusual or incorrect assignment of sig- baseline and after 15 days was not significant. Patients with psy- nificance or importance to otherwise innocuous stimuli and is chotic symptoms showed higher ASI total score than patients thought to have a crucial role in the onset of psychosis. Aberrant without them (p < 0.001). The Italian Version of the ASI showed salience inventory (ASI) is the only self-reported questionnaire high internal consistency (Cronbach’s alpha = 0.89) and good for the assessment of aberrant salience. Accordingly, the main test-retest reliability (r = 0.96, p < 0.001). aim of the present paper was to validate the Italian Version of the ASI. Conclusions The Italian Version of the ASI was shown to be a valid and reli- Methods able instrument with good psychometric properties. Its useful- The Italian Version of the ASI was administered to a group of ness in investigating aberrant salience and psychosis proneness 112 subjects (48 psychiatric outpatients and 64 subjects from was confirmed. the general population). Comparisons between patients and controls at two different times (baseline and after 15 days) were Key words made. The relationship between ASI and the presence of psychotic symptoms, internal consistency and test-retest reliability Aberrant salience • Psychotic proneness • Psychotic symptoms of the Italian version of the ASI were analysed. • Validation study

Introduction of salience or significance”, the features of stimuli are compared to their context and, depending on their level Delusions and hallucinations are psychotic symptoms and of “saliency”, demand attention, drive action and influ- represent a common experience, not only in people with ence goal-directed behaviour due to their association with schizophrenia-spectrum disorders, but also in those at risk reward or punishment 3-5. 1 for psychosis . Previous research reported that the onset Frequently, during the prodromal phase, stimuli that or- of psychotic disorders is often slow and gradual, with a dinarily might be considered insignificant, become much prodromal period ranging from several weeks to several more salient and relevant. In these circumstances, sali- 2-5 years or longer . ence is defined as “aberrant” 3 4. Situations where a stimu- In this prodromal phase, patients report an unusual or lus may be valued as salient are: feature novelty (e.g. a incorrect assignment of salience or significance (aber- new object in an otherwise familiar environment); con- rant salience) to innocuous stimuli, and this has been trast (e.g. an intense light flashing in a dark room) and hypothesised to be a central mechanism in the develop- emotional/motivational association (e.g. a previously neu- ment of psychosis 6 7. Salience can be defined as a process tral stimulus that has been linked with reward or punish- whereby objects and representations, through the process ment). In particular, “motivational salience” seems to be of association, come to be attention-grabbing and capture relevant to psychosis. Actually, when a neutral stimulus thought and behaviour. During the process of “attribution is pervaded by an emotional quality, due to its associa-

Correspondence Lorenzo Lelli, Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, largo Brambilla 3, 50134 Fire- nze, Italy • Tel./Fax +39 055 7947487 • E-mail: [email protected]

Journal of Psychopathology 2015;21:281-286 281 L. Lelli et al.

tion with primary reinforcement, influence on behaviour and heightened cognition. The first factor (feelings of and cognitive functions may occur 5 6. In 2003, Kapur 7 increased significance) represents the core of Kapur’s proposed the “aberrant salience” hypothesis of psychosis, theory, relative to the increased salience to otherwise linking the aberrant signalling of motivational salience to innocuous stimuli, and may be the process that drives psychotic symptoms. Under normal circumstances, the the experience of the other four factors. The second fac- context driven activity of the dopamine system mediates tor includes anomalies of perception, such as subjective the experience of novelty and, thus, the acquisition of feelings of sharpening of senses, and aberrant salience appropriate motivational salience 5 8-10. could have a role in determining this experience 16. The It has been hypothesised that in schizophrenia, genetic third factor, the impending understanding, indicates the predispositions and environmental perturbations (i.e. experience of increased feelings of salience that lead to pre- and perinatal adverse events) 11 facilitate an al- a breakthrough in understanding. The fourth and fifth teration in the dopamine system, causing dopamine re- factors, heightened emotionality and heightened cogni- lease, which is independent from the context. Accord- tion, are relative to the attempts of a person to under- ingly, in the prodromal phase, a context-independent stand the emotions and cognitions that accompany an or context-inappropriate firing of dopamine neurons aberrant salience experience, but could be more gener- and dopamine release has been reported 2. The normal ally pre-psychotic experiences 16. process of context-driven novelty and salience attribu- The moderate to high correlation of the above-mention, mediated by dopamine, is exchanged with an ab- tioned factors was demonstrated in Study 2, where a errant and endogenously driven assignment of salience second-order model led to the conclusion that a single to stimuli 7. second-order factor (i.e. ASI total score) conceptualises This hypothesis is supported by a consistent body of re- the construct of aberrant salience 16. Study 2 reported search and is in favour of an association between psycho- that the ASI is correlated with many constructs, hypoth- sis and increased subcortical dopamine 12 13. For exam- esised to include its nomological network, involving ple, brain imaging studies have reported irregular dopa- magical ideation, referential thinking, perceptual aber- mine activity in people with schizophrenia, either during ration, dissociation and absorption. Furthermore, Study the active phase of psychosis 14 or in the prodromal phase 2 supported the scale score’s convergent validity, as the of the disorder 15. Therefore, both phenomenological and ASI is strongly associated with psychosis-proneness and neurobiological studies sustain a role for aberrant sali- dissociation measures, and moderately correlated with ence in psychosis. measures associated with dopamine levels 16. This study For these reasons, the evaluation of aberrant salience can also provided results for its discriminant validity, as the be useful for early diagnosis, but until recently few instru- ASI is only weakly associated with social anhedonia. ments have been developed to measure it and there is on- Study 3 reported that participants with elevated psy- ly one self-report questionnaire: the aberrant salience in- chosis proneness had an increase in ASI scores, but, in ventory (ASI). The ASI 16 is a valid and reliable tool which contrast, people with high social anhedonia had scores measures aberrant salience in people at risk for develop- that were similar to comparison participants 16. Study 4 ing psychosis. It represents a specific instrument, highly showed that subjects with a history of psychosis had el- correlated with other measures of psychotic-like experi- evated ASI scores in comparison with a psychiatric con- ences, such as the perceptual aberration 17 and magical trol group. The mean score of the ASI for patients with ideation scales 18. Moreover, the ASI is correlated with a history of psychosis was 15.17, while patients without behavioural activation, which seems to reflect increased a history of psychosis showed a mean of 11.50 16. The subcortical dopamine, and is less strongly correlated with research also provided support for the internal consist- social anhedonia 16. ency reliability of ASI scores (Cronbach’s alpha 0.89) The ASI items were created by David C. Cicero and John and demonstrated that ASI has valid psychometric prop- G. Kerns considering phenomenological descriptions erties. The ASI had a Cronbach’s alpha of 0.91 in the of the initial experience of psychosis 7 19-21, reports of history-of-psychosis group and 0.80 in the comparison the prodromal phase of schizophrenia 2 4 22 and tran- group 16. Thus, ASI may be useful in evaluating aberrant scripts of interviews of people with schizophrenia 23 24. salience and psychosis proneness, in both clinical and The language used for the item construction is simple nonclinical samples. No test-retest reliability was per- and appropriate for the target population; double-bar- formed in the original validation study 16. relled items were avoided. A series of four studies were As aberrant salience has a crucial role in psychosis and designed to develop and validate the questionnaire 16. an Italian Version of the ASI is lacking, the aim of this Study 1 showed that ASI is composed of five factors: work was to translate and verify the psychometric proper- feelings of increased significance, sense sharpening, ties of the Italian version of the ASI in a clinical sample impending understanding, heightened emotionality and a healthy control group. Internal consistency, test-

282 Validation of the Italian Version of the Aberrant Salience Inventory (ASI): a New Measure of Psychosis Proneness

retest reliability and discriminant validity have been spe- pecially strong or clear?), impending understanding (e.g., cifically addressed. Do you sometimes feel like you are on the verge of some- thing really big or important but you aren’t sure what it Materials and Methods is?),heightened emotionality (e.g., Do you go through periods in which you feel over-stimulated by things or expe- The present study included 112 subjects, 48 consecutive riences that are normally manageable?), and heightened psychiatric outpatients (13 with schizophrenia, 12 with cognition (e.g., Do you ever feel like the mysteries of the major depression, 12 with bipolar disorder, 7 with anxi- universe are revealing themselves to you?). A Yes answer ety disorder and 4 with eating disorder) and 64 subjects corresponds to 1 at scoring, while a No answer corre- recruited from the general population. sponds to zero, and thus the maximum total score is 29. Outpatients were attending the Psychiatric Outpatient The Italian Version of the ASI was administered to all sub- Service of the Department of Neuroscience, Psychol- jects at baseline (test-T0) and after 15 days (retest-T1). ogy, Drug Research and Child Health at the University The current research protocol was approved by the Ethics Hospital in Florence (Italy), between September 1, 2013 Committee of the Institution and the study was performed and October 31, 2013. Inclusion criteria were as follows: in accordance with the principles of the 1983 Declara- age 18-65 years, DSM-IV-TR diagnosis 25 of any mental tion of Helsinki. All participants provided informed con- disorder except for mental retardation, clinically stable sent prior to completing the study. condition of the mental disorder in the last 3 months, no changes in pharmacotherapy in the last 3 months and no start or interruption of psychotherapy in the last 3 months. Statistical analysis Sociodemographic data were assessed by an expert psy- Continuous variables were reported as mean ± standard chiatrist (A.B.) at the beginning of the visit, together with deviation, whereas categorical variables were reported the anamnestic data. In this clinical interview the previ- as percentage. For assessment of between-group differ- ous or present history of psychotic symptoms (hallucina- ences (psychiatric patients vs. controls and patients with tions and/or delusions) was thoroughly investigated. The psychotic symptoms vs. patients without psychotic symp- presence of psychotic symptoms was defined as “detect- toms), chi-square and independent measures t-test were ed”, and the absence was defined as “undetected”. applied for categorical and continuous variables, respec- Diagnosis was made with DSM-IV-TR criteria using a tively. A paired t-test was used to compare ASI total score face-to-face interview (Structured Clinical Interview for at T0 and at T1. DSM-IV-TR, SCID-I/P) 26. Exclusion criteria were as fol- Pearson’s correlation analyses were performed to assess lows: mental retardation, age < 18 years or > 65 years, the test-retest reliability on ASI total score, while Spear- severe phase of disorder with unstable clinical condition man’s rank correlation coefficients of individual ASI items in the last 3 months, or changes in pharmacotherapy or were calculated at T0 and at T1. In order to measure the psychotherapy in the last 3 months. internal consistency of the ASI scale, Cronbach’s alpha A group of 64 individuals, drawn from the general popu- was calculated at T0 and at T1. lation living in the same catchment area, composed the Statistical analyses were carried out using the Statistical controls and were recruited from the lists of the Italian Package for the Social Sciences, version 20.0 (SPSS Inc., National Health System (NHS) (99.7% of citizens are in- Chicago, IL., USA). cluded in the list of the NHS). Controls were aged 18-65 years and did not meet DSM-IV-TR criteria for any mental Results disorder (evaluated by the SCID-I/NP) 27. The Italian Translation of the ASI was carried out separate- The mean age of the sample was 34.40 ± 13.27 years ly by two different official mother-tongue translators. The (controls: 31.92 ± 10.93; patients: 36.56 ± 13.96; two Italian translations were revised and merged in or- t = -1.90; p = 0.06) and 38.4% were males (controls: der to create a final version which was back-translated in 39.1%; patients: 37.5%; χ2 = .03; p = 0.08). Mean years English by a third official translator. This back-translated of education were 13.44 ± 3.97 (controls: 14.75 ± 3.42; version was compared with the original version by Cic- patients: 11.61 ± 3.92; t = 4.43; p < 0.05) and 54.20% ero to verify the good quality and adequacy of the final of the sample was single or divorced (controls: 76.5%; Italian version. The ASI is a 29-item yes-no questionnaire patients: 22.7%; χ2 = 41.6; p < 0.05). Psychotic symp- that has five subscales measuring different aspects of the toms were detected in 62.5% (n = 30) of psychiatric out- experience of aberrant salience including feelings of inpatients (n = 13 schizophrenia, n = 12 bipolar disorder, creased significance (e.g., Do certain trivial things sud- n = 5 major depression), while they were not reported by denly seem especially important or significant to you?), any control subjects (χ2 = 54.63; p < 0.001). sharpening of senses (e.g., Do your senses ever seem es- ASI mean total score at baseline (T0) was 7.52 ± 4.56

283 L. Lelli et al.

for controls and 12.48 ± 7.52 for patients (t = -4.05, nosis and treatment 29 30. For these reasons, according to p < 0.001), while after 15 days, at retest (T1), controls a dimensional approach to these symptoms 31, we sustain scored 7.33 ± 4.42 and psychiatric sample scored that this questionnaire may be useful in prevention pro- 12.04 ± 7.76 (t = -3.77, p < 0.001). Comparing ASI total grams both in large community samples and in clinical score at T0 and at T1, in both groups, no significant differ- settings, and we suggest the inclusion of the ASI in clini- ence was observed (for controls, t = 1.28, p = 0.203; for cal assessment. patients, t = 1.29, p = 0.200). One limitation of the study is that the total sample size was Test-retest reliability for ASI total score was 0.97 small, but data on reliability provided good results. Ac- (p < 0.001) for controls, 0.95 (p < 0.001) for patients cordingly, a wider follow-up study should be performed and 0.96 (p < .001) in the total sample. Non-parametric in the future to evaluate if salience changes across time Spearman correlations for each item showed a strong cor- and different clinical stages of the disorders. Moreover, relation between items of ASI at T0 and at T1 (r = 0.68- validity of the scale was not addressed in the present pa- 0.95, p < 0.001). per, as it was previously demonstrated by Cicero et al. 16. Cronbach’s alpha coefficient was 0.89 at T0 and 0.89 at T1, meaning a high internal consistency. Conclusions Patients with psychotic symptoms (n = 30) showed higher ASI total scores than patients without such symptoms The Italian Version of the ASI was validated and showed (n = 18) (T0: 14.53 ± 7.29 vs. 7.85 ± 5.11, t = -4.62, good psychometric properties with a Cronbach’s alpha p < 0.001; T1: 14.23 ± 7.17 vs. 7.56 ± 5.21, t = -4.66, coefficient of 0.89, meaning a high internal consistency, p < 0.001). Moreover, patients without psychotic symp- and test-retest reliability of 0.96. Moreover, higher mean toms did not differ from controls, in ASI total scores at scores of the ASI clearly distinguish patients from con- both assessments. trols and patients with psychotic symptoms from patients without such symptoms, demonstrating discriminant va- Discussion lidity of the scale and its ability to individuate psychotic patients. The reliability and validity, simple language The main goal of the current research was to translate and used, ease of administration and self-reported nature of verify the internal consistency and test-retest reliability of this tool, suggests that the ASI could be used with the the Italian version of the self-report questionnaire ASI. general population. The Italian Version of the ASI demonstrated good psycho- In fact, future and wider prevention and screening pro- metric properties, showing both high internal consistency grams could adopt the ASI as a useful tool to identify sub- and test-retest reliability, as well as discriminant validity. jects at risk for the development of psychosis and to iso- Differing from the original validation study by Cicero, we late a cluster of subjects where a deeper and more careful evaluated the test-retest reliability after 15 days. During psychopathological assessment is needed. It could also this short span of time, the patient’s therapy was not mod- be of interest to follow these subjects across time in a ified, in order to exclude a drug-induced interference longitudinal perspective and to analyse the clinical and with the dopamine system linked to salience. Test-retest psychopathological course of symptoms. reliability had good results. Psychometric properties had A longitudinal study design could eventually confirm the 16 28 good results both in patients and the control group . prognostic value of the aberrant salience process as a pre- Moreover, higher mean scores of the ASI clearly distin- dictor of the development of psychosis. guish between patients from controls and patients with psychotic symptoms from patients without such symp- Conflict of interest toms, demonstrating the discriminant validity of the scale. None. This finding is consistent with previous observations 16 and could suggest the introduction of a cut-off score that distinguishes subjects with psychosis proneness among clinical References and non-clinical populations. Cicero et al. 16 reported a 1 Andreasen NC, Arndt S, Alliger R, et al. Symptoms of schizo- mean ASI score of 13.73 in a nonclinical sample, which phrenia. Methods, meanings, and mechanisms. Arch Gen means that participants answered Yes to 14 items, which Psychiatry 1995;52:341-51. is in line with the results of the present study. Therefore, a 2 Yung AR, McGorry PD. The prodromal phase of first episode score of 14 is suggested as a cut-off value. psychosis: past and current conceptualizations. Schizophr Originally, the ASI was created to measure lifetime occur- Bull 1996;22:353-70. rence or trait aberrant salience in nonclinical samples. In 3 Bowers MB Jr. Pathogenesis of acute schizophrenic psy- fact, it may help identify people at risk for the develop- chosis: An experimental approach. Arch Gen Psychiatry ment of psychosis, thus improving prevention, early diag- 1968;19:348-55.

284 Validation of the Italian Version of the Aberrant Salience Inventory (ASI): a New Measure of Psychosis Proneness

4 Moller P, Husby R. The initial prodrome in schizophrenia: chosis. An experimental approach. Arch Gen Psychiatry Searching for naturalistic core dimensions of experience and 1968;19:348-55. behavior. Schizophr Bull 2000;26:217-32. 20 Gottesman I. Schizophrenia genesis: The origins of mad- 5 Berridge KC, Robinson TE. What is the role of dopamine in ness. New York, NY: Freeman 1991. reward: hedonic impact, reward learning, or incentive sa- 21 Parnas J, Handest P, Saebye D, et al. Anomalies of subjective lience? Brain Res. Rev 1998;28:309-69. experience in schizophrenia and psychotic bipolar illness. 6 Milstein DM, Dorris MC. The influence of expected value on Acta Psychiatr Scand 2003;108:126-33. saccadic preparation. J Neurosci 2007;27:4810-18. 22 Thomas L E, Woods S W. The schizophrenia prodrome: a 7 Kapur S. Psychosis as a state of aberrant salience: a frame- developmentally informed review and update for psycho- work linking biology, phenomenology, and pharmacology in pharmacologic treatment. Child Adolesc Psychiatr Clin N schizophrenia. Am J Psychiatr 2003;160:13-23. Am 2006;15:109-33. 8 Shizgal P. Neural basis of utility estimation. Curr Opin Neu- 23 Kerns JG, Berenbaum H. The relationship between formal robiol 1997;7:198-208. thought disorder and executive functioning component pro- 9 Berridge KC. Pleasure, pain, desire and dread: hidden core cesses. J Abnorm Psychol 2003;112:339-52. processes of emotion. In: Well-being: the Foundations of He- 24 Kerns JG. Verbal communication impairments and cognitive donic Psychology. New York: Russel Sage Foundation 1999. control components in people with schizophrenia. J Ab- 10 Heinz A. Anhedonia – general nosology surmounting cor- norm Psychol 2007;116:279-89. relate of a dysfunctional dopaminergic reward system? Ner- 25 American Psychiatric Association. Diagnostic and Statistical venarzt 1999;70:391-98. Manual - Text Revision. Washington, DC: American Psychi- 11 Lewis DA, Levitt P. Schizophrenia as a disorder of neurode- atric Association 2000. velopment. Annu Rev Neurosci 2002;25:409-32. 26 First MB, Gibbon M, Spitzer RL, et al. Structured Clinical 12 Seeman P. Dopamine receptors and the dopamine hypoth- Interview for DSM-IV-TR Axis I Disorders, Research Version, esis of schizophrenia. Synapse 1987;1:133-52. Patient Edition (SCID-I/P). New York: Biometrics Research, New York State Psychiatric Institute 2002. 13 Winton-Brown TT, Fusar-Poli P, Ungless MA, et al. Dopami- 27 nergic basis of salience dysregulation in psychosis. Trends First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Neurosci 2014;37:85-94. Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition (SCID-I/NP). New York: Biometrics Re- 14 Laruelle M, Abi-Dargham A. Dopamine as the wind of the search, New York State Psychiatric Institute 2002. psychotic fire: new evidence from brain imaging studies. J 28 Cicero DC, Becker TM, Martin EA, et al. The role of aber- Psychopharmacol 1999;13:358-71. rant salience and self-concept clarity in psychotic-like expe- 15 Howes OD, Montgomery AJ, Asselin MC, et al. Elevated stri- riences. Personal Disord 2013;4:33-42. atal dopamine function linked to prodromal signs of schizo- 29 McGlashan TH, Zipursky RB, Perkins D, et al. Randomized, phrenia. Arch Gen Psychiatry 2009;66:13-20. double-blind trial of olanzapine versus placebo in patients 16 Cicero DC, Kerns JG, McCarthy DM. The Aberrant Salience prodromally symptomatic for psychosis. Am J Psychiatry Inventory: A new measure of psychosis proneness. Psychol 2006;163:790-99. Assess 2010;22:688-701. 30 Compton MT, McGlashan TH, McGorry PD. Toward pre- 17 Chapman LJ, Chapman JP, Raulin ML. Body-image aber- vention approaches for schizophrenia: An overview of pro- ration in schizophrenia. J Abnorm Psychol 1978;87:399- dromal states, the duration of untreated psychosis, and early 407. intervention paradigms. Psychiatr Ann 2007;37:340-48. 18 Eckblad M, Chapman LJ. Magical ideation as an indicator of 31 Sbrana A, Benvenuti A, Rucci P, et al. The psychotic spec- schizotypy. J Consul Clin Psychol 1983;51:215-25. trum: development and theoretical foundations. Giorn Ital 19 Bowers MB Jr. Pathogenesis of acute schizophrenic psy- Psicopat 2006;12: 352-58.

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Italian Version of the Aberrant Salience Inventory (ASI) Istruzioni: con questo questionario intendiamo indagare le tipologie di atteggiamento e di esperienze di vita delle persone. Il seguente questionario contiene domande proprio su questi aspetti. Per favore, risponda “SI” o “NO” facendo una crocetta dopo ciascuna domanda. Quando pensera a se stesso e alla sua esperienza, non consideri significativi quegli atteggiamenti, sensazioni o esperienze che eventualmente avesse sperimentato sotto l’effetto di alcol o altre sostanze (ad es. marijuana, LSD, cocaina).

Sì No 1. Le e mai capitato che alcune cose di poco conto le siano apparse improvvisamente importanti o significative? 2. Le succede, talvolta, di sentirsi come alla soglia di qualcosa di veramente grande, ma non e sicuro di che cosa si tratti? 3. Le capita, qualche volta, che le sue capacita sensoriali le sembrino acute? 4. Si e mai sentito come se stesse rapidamente per raggiungere il massimo delle sue capacita intellettive? 5. Le capita, qualche volta, di prestare attenzione a certi dettagli non notati in precedenza che vengono ad assumere un certa rilevanza per lei? 6. Le succede di sentirsi come se ci fosse qualcosa di importante (per lei) da capire, ma non e sicuro di che cosa si tratti? 7. Ha mai passato periodi in cui si e sentito particolarmente religioso o contemplativo? 8. Ha mai avuto difficolta a distinguere se si sente eccitato, spaventato, sconcertato o in ansia? 9. Ha mai attraversato dei periodi di maggiore consapevolezza sulle cose? 10. Ha mai sentito il bisogno di dare un senso a situazioni o avvenimenti apparentemente casuali? 11. Qualche volta le capita di sentirsi come stesse trovando il pezzo mancante di un puzzle? 12. A volte si sente come se potesse udire le cose con maggior chiarezza? 13. A volte si sente come se fosse una persona particolarmente evoluta dal punto di vista spirituale? 14. Osservazioni di norma insignificanti, a volte assumono per lei un significato infausto? 15. Attraversa dei periodi in cui le canzoni talvolta assumono significati rilevanti per la sua vita? 16. Qualche volta le capita di sentirsi sul punto di comprendere qualcosa di veramente grande o importante, ma non sa con certezza cosa sia? 17. Il suo senso del gusto le e mai sembrato piu fine? 18. Ha mai avuto la sensazione che i misteri dell’universo fossero sul punto di rivelarsi a lei? 19. Le capita di passare periodi in cui si sente eccessivamente stimolato da oggetti o esperienze che normalmente sono gestibili? 20. Rimane spesso affascinato dalle piccole cose che la circondano? 21. I suoi sensi le sembrano mai estremamente spiccati o chiari? 22. Si sente mai come se un intero mondo le si stesse rivelando? 23. Si e mai sentito come se i confini fra le sue sensazioni interne ed esterne fossero stati tolti? 24. Qualche volta le succede di avere la sensazione che il mondo stia cambiando e che lei debba trovare una spiegazione? 25. Ha mai percepito un significato travolgente in cose che normalmente per lei non sono significative? 26. Hai mai sperimentato una sensazione inesprimibile di urgenza in cui non era sicuro sul da farsi? 27. Le e mai capitato di sviluppare un particolare interesse per persone, eventi, luoghi o idee che normalmente non attirerebbero in quel modo la sua attenzione? 28. Le capita mai che i suoi pensieri e le sue percezioni diventino troppo rapidi per essere ben assimilati? 29. A volte nota cose a cui non aveva prestato attenzione in precedenza e che invece vengono ora ad assumere un significato speciale?

286 Assessment and instruments in psychopathology

Italian version of the “Specific Level of Functioning” Versione italiana della “Specific Level of Functioning”

C. Montemagni1, P. Rocca1, A. Mucci2, S. Galderisi2, M. Maj2

1 Department of Neuroscience, University of Turin, Turin, Italy; 2 Department of Psychiatry, University of Naples SUN, Naples, Italy

Summary review by experts were carried out. The operational equivalence was taken into account, which preserves the original features. Objectives The assessment of real-life functioning presents complex chal- Results The Italian version of the SLOF is a 43-item multidimensional lenges from variability in the operational definition of functional behavioural survey comprising six subscales: (1) physical func- outcome to problems in identifying optimum information sourc- tioning, (2) personal care skills, (3) interpersonal relationships, es. In this context, there are still few satisfactorily reliable instru- (4) social acceptability, (5) activities of community living and ments for the assessment of functional outcomes that are practi- (6) work skills. It is administered in person to the caseworker or cal in terms of time involved, and most real-life functional out- caregiver of a schizophrenic patient or a patient-administered come scales seem to be largely redundant with each other when scale completed with verbal instructions from the examiner to utilised simultaneously. The Validation of Everyday Real-World rate its own performance. The scale does not include items rel- Outcomes (VALERO) Study selected six functional outcome evant to psychiatric symptomatology or cognitive dysfunctions, scales from a much larger group of candidate scales as most suit- but assesses the patient’s current functioning and observable be- able for current use. The Specific Levels of Functioning (SLOF) haviour, as opposed to inferred mental or emotional states, and Scale was one of these and was considered to be a hybrid scale focuses on a person’s skills, assets, and abilities rather than deficits that once served as the central paradigm guiding assessment rating multiple functional domain. This scale has been translated and intervention for persons with disabilities. into Italian by our group, and the translation is presented herein. Conclusions Methods Ratings on individual items of the SLOF may be used to capture In the context of the multicentre study of the Italian Network for the current state of overall functioning while showing specific Research on Psychoses, the SLOF was translated in Italian by two areas of therapeutic and rehabilitative need. Moreover, the SLOF psychiatrists and then back-translated. A formal assessment of se- has direct applications in research on patient outcomes and mantic equivalence, debriefing of conventional sample and final evaluation of programmes.

Introduction tioning, including self-report interviews, proxy reports, informant interviews 4, direct observations by trained Despite significant advances in pharmacological and psy- clinicians 5, and performance-based measures, which chological treatments, patients with schizophrenia show assess functional capacity (“what the individual can do impairment in everyday functioning, with deficiencies in under optimal conditions”) 6. However, reports of real- social, cognitive and real-life activities, including independent living, productive activities and social relation- life outcomes vary across informants and contain ele- 4 ships, that are detectable at the time of the first episode ments of error or shortcomings . It has been suggested of illness and commonly observed in patients through that self-reports should be accepted at face value even if 7 the course of illness, even among patients who respond they reflect patients’ delusional beliefs and have limita- to antipsychotics and have only residual psychotic symp- tions such as inaccurate estimations 8. Other investigators toms 1-3. The assessment of real-life functioning presents have highlighted the potential for psychotic symptoms, complex challenges from variability in the operational mood states, disorganised thinking, lack of insight, and definition of functional outcome to problems in identify- neurocognitive deficits to limit the usefulness of the self- ing optimum information sources 4. Indeed, many differ- report methodology in severely ill schizophrenia patients. ent strategies have been proposed to assess real-life func- Furthermore, it has been suggested that these measures

Correspondence Paola Rocca, Department of Neuroscience, Unit of Psychiatry, University of Turin, Turin, Italy • Tel. 0039-011-6634848 • Fax 0039-011-673473 • E-mail: [email protected]

Journal of Psychopathology 2015;21:287-296 287 C. Montemagni et al.

may not adequately reflect the effects of various interven- or any combination of these. The scale characteristics, tions 9. However, studies have shown that patient self- which were rated by the panellists and were similar to reports of everyday functioning in schizophrenia often do those deemed important in the MATRICS process, were: not converge with objective evidence or the reports of reliability (test-retest and interrater), convergence with others 10 11. Self-reports of functioning therefore appear performance-based measures of functional capacity and problematic, and alternative assessment methods may be neurocognitive performance, sensitivity to treatment ef- required. However, many patients have no caregivers to fects, usefulness for multiple informants (e.g., self, friend provide information, and variance in their reports can be or relative, case manager, or prescriber), relationships influenced by the amount of contact with the subject and with symptom measures, practicality and tolerability for situation specificity of the observation. High contact cli- people with low education levels, and convergence with nicians appear to generate ratings of everyday function- other measures of real-life functional outcomes (including that are more closely linked to patients’ ability scores ing either other rating scales or achievement milestones). than friends or relative informants 12. Both types of direct Among the 59 measures nominated, the investigators se- assessment (direct observation versus analogue assess- lected the 11 scales that were the most highly nominat- ment) have advantages and limitations. Real-life observa- ed, had the most published validity data regarding their tions are necessarily individualised and non-standardised psychometric qualities and best represented the domains as well as costly and potentially reactive (presence of an of interest (social functioning, everyday living skills, or observer may alter the environment and resulting behav- both these areas -”hybrid” scales). Scales were rated on iours). To this end, performance-based measures of func- a 9-point (1-9) scale, where scores of 1-3 were poor, 4-6 tional capacity have been developed. However, they are were fair to good and 7-9 were very good to superb. valid to the extent that they measure the relevant skills The two scales that scored highest across the various accurately, but other factors may influence real-life out- criteria for each of the classes of scales (hybrid, social comes, such as financial resources, motivation and symp- functioning, and everyday living skills) were selected for toms of the illness may limit the extent to which skills use in the first substudy of VALERO 4. The scales selected that are present in the behavioural repertoire are actually were the Quality-of-Life Scale, Specific Levels of Func- performed in real-life settings 13. tioning Scale, Social Behavior Schedule, Social Function- ing Scale, Independent Living Skills Schedule, and Life Overview of everyday real-life outcomes Skills Profile. The overall results of this first substudy of VALERO show that all examined scales can be consid- In this context, research efforts are increasingly turning to ered as somewhat useful in their current versions. Moreo- the design, evaluation and improvement of relatively eco- ver, many of these scales lack critical data regarding relia- nomical real-life measurement 14-16. Moreover, given con- bility across investigators and relationship with neuropsy- cerns about length and ease of administration, as well as chiatric and functional capacity performance. Ratings for burden to the subject for assessment batteries, a practical usefulness across multiple raters were also quite low, measure must be both cost efficient and require a modest partly because many of these scales do not have alternate amount of time to administer 14. However, there are still forms that attempt to capture the differing perspectives few satisfactorily reliable instruments for the assessment of different raters. As an entirely effective measure of the of functional outcomes that are practical in terms of time real-life outcomes component of the functional outcomes involved, and most real-life functional outcome scales construct has not yet been identified, some measures are seem to be largely redundant with each other when uti- likely to be suitable in the interim. Thus, comprehensive lised simultaneously. One upshot of this situation is the real-life functioning assessment, using self-report, inform- Validation of Everyday Real-World Outcomes in schiz- ant report and interviewer best judgment across six differ- ophrenia (VALERO Expert panel) initiative. This project ent real-life functioning rating scales may be required to represents a joint effort between researchers at Emory capture the complexity of functional outcome in schizo- University and the University of California, San Diego. phrenia 13. However, a through description of these scales The goal of this initiative was to identify the functional is beyond the scope of this paper, in which we focused on rating scale or scales (or subscales from existing scales) the Specific Level of Functioning. (self-report and informant-based reports) most strongly The Specific Levels of Functioning (SLOF) Scale 17 is a related to performance-based measures of cognition and 43-item multidimensional behavioural survey adminis- everyday living skills through a comprehensive evalua- tered in person to the caseworker or caregiver of a schiz- tion of existing instruments 4. Forty-eight experts were ophrenic patient, selected on the basis of his/her familiar- asked to nominate the scales that they think best measure ity with that person or a patient-administered scale com- everyday outcomes in schizophrenia. The outcomes may pleted with verbal instructions from the examiner to rate include social, vocational, independent living, self-care, its own performance. The scale does not include items

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relevant to psychiatric symptomatology or cognitive dys- of the SLOF 18 is derived from the original SLOF, and has functions, but assesses the patient’s current functioning also demonstrated good psychometric properties, main- and observable behaviour, as opposed to inferred mental taining the same factorial structure as the original 17 in a or emotional states, and focuses on a person’s skills, as- much larger (n=895) and more homogenous (community sets, and abilities rather than deficits that once served as sample) sample. The six factors identified (Activities, In- the central paradigm guiding assessment and intervention terpersonal relationships, Work skills, Personal care skills, for persons with disabilities. It comprises six subscales: Social acceptability, and Physical functioning) explained (1) physical functioning, (2) personal care skills, (3) in- 57.1% of the item variance, comparable to the one re- terpersonal relationships, (4) social acceptability, (5) ac- ported in the original study for community sample (58%). tivities of community living and (6) work skills. The work The variance explained by each factor was respectively skills domain comprises behaviours important for voca- 30.7%, 7.7%, 6.2%, 5.0%, 4.2% and 3.3% (expressed tional performance, but is not a rating of behaviour dur- as percentage of the total variance, these figures corre- ing employment. The latter would not be feasible, since spond to 53.8%, 13.5%, 10.8%, 8.7%, 7.3% and 5.8%, the majority of patients with schizophrenia are unem- respectively). The factor order is equivalent between the ployed; therefore, the proxy measure of work skills from study by Mucci et al. 18 and the original one, as the Social the SLOF is used. Lastly, the SLOF also includes an open- ended question asking the informant if there are any oth- acceptability and Physical functioning factors explain the er areas of functioning not covered by the instrument that lowest amount of variance. The inter-rater reliability for may be important in assessing functioning in this patient. each of the six domains has shown a good to excellent Each of the questions in the above domains is rated on a agreement among raters, being higher in the community 5-point Likert scale. Scores on the instrument range from than in the hospital samples. Moreover, the authors of the 43 to 215. The higher the total score, the better the overall scale recommend that to foster the SLOF inter-rater reli- functioning of the patient. According to the original ver- ability, assessments should be performed by an informant sion of the SLOF, the time frame covered by the survey is who knows “well” the client’s skills and behaviour. Thus, the past week. Each informant is asked to rank how well in case of hospitalised patients, he/she should not be as- they know the patient on a 5-point Likert scale ranging sessed immediately following entry into an agency, but from “not well at all” to “very well.” Ratings on individual only after staff have interacted with him or her several items of the SLOF may be used to capture the current times and observed the individual in many situations and state of overall functioning while showing specific are- circumstances 17. as of therapeutic and rehabilitative need, i.e. to identify goals in planning treatment for clients, to develop special intervention or skill-training programs, or to assign clients SLOF: Italian translation with similar or complementary strengths and needs to ex- In the context of the multicentre study of the Italian isting programmes. An adaptation of the SLOF is to allow Network for Research on Psychoses the instrument was patients to rate themselves on each item, while staff make translated in Italian (two independent translations of the independent judgments. Patients and staff then share their scale were made by two psychiatrists; PR and AM, expe- ratings, discuss discrepancies and negotiate a mutually rienced in this area, fluent in English, and able to identify acceptable set of functionally oriented goals for the plan. the concept covered by each of the original items) and This process also could serve as a form of quality assur- then back-translated, according to the method proposed ance, allowing patients and staff to obtain potentially by Herdman et al. 19. A formal assessment of semantic valuable feedback about the patients’ self-perceptions equivalence, a debriefing of conventional sample and a and help staff to gauge better the accuracy of their judg- final review by experts were carried out. The operational ments 17. Lastly, the SLOF has direct applications in re- equivalence was taken into account, which preserves search on patient outcome and programme evaluation. the original features. For this purpose, we kept the same number of fields, same statements and same option of SLOF: psychometric features scoring and qualification. The SLOF was found to be a reliable and valid scale, with This is the first comprehensive English language report on a good construct validity and internal consistency, as well the development of the Italian version of the SLOF. as a stable factor structure. In Appendix A the Italian translation of the SLOF is pre- In the context of a multicentre study of the Italian Network sented. for Research on Psychoses, Mucci et al. 18 explored the construct validity, internal consistency and factor struc- Conflict of interest ture of the Italian version of the SLOF. The Italian version None.

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References 11 McKibbin C, Patterson TL, Jeste DV. Assessing disability in older patients with schizophrenia: results from the WHO- 1 Wiersma D, Wanderling J, Dragomirecka E. Social disability DAS-II. J Nerv Ment Dis 2004;192:405-13. in schizophrenia: its development and prediction over 15 years in incidence cohorts in six European centres. Psychol 12 Sabbag S1, Twamley EM, Vella L, et al. Assessing everyday Med 2000;30:1155-67. functioning in schizophrenia: not all informants seem equal- 2 Ho BC, Andreasen N, Flaum M. Dependence on pubic fi- ly informative. Schizophr Res 2011;131:250-5. nancial support early in the course of schizophrenia. Psychi- 13 Bowie CR, Reichenberg A, Patterson TL, et al. Determinants atr Serv 1997;48:948-50. of real-world functional performance in schizophrenia sub- 3 Velligan DI, Mahurin RK, Diamond PL, et al. The functional jects: correlations with cognition, functional capacity, and significance of symptomatology and cognitive function in symptoms. Am J Psychiatry 2006;163:418-25. schizophrenia. Schizophr Res 1997;25:21-31. 14 Bellack A, Green MF, Cook JA. Assessment of community 4 Leifker FR, Patterson TL, Heaton RK, et al. Validating meas- functioning in people with schizophrenia and other severe ures of real-world outcome: the results of the VALERO Expert mental illnesses: a white paper based on an NIMH-spon- Survey and RAND Panel. Schizophr Bull 2011;37:334-43. sored workshop. Schizophrenia Bulletin 2007;33:805-22. 5 Kleinman L, Lieberman J, Dube S, et al. Development and 15 Llorca PM, Lancon C, Lancrenon S. The “Functional Remis- psychometric performance of the schizophrenia objective sion of General Schizophrenia” (FROGS) scale: develop- functioning instrument: an interviewer administered meas- ment and validation of a new questionnaire. Schizophrenia ure of function. Schizophr Res 2009;107:275-85. Research 2009;115:218-25. 6 Harvey PD, Velligan DI, Bellack AS. Performance-based 16 Mausbach BT, Moore R, Bowie B. A review of instruments measures of functional skills: usefulness in clinical treatment for measuring functional recovery in those diagnosed with studies. Schizophr Bull 2007;33:1138-48. psychosis. Schizophrenia Bulletin 2009;35:307-18. 7 Orley J, Saxena S, Herrman H. Quality of life and mental ill- 17 ness. Reflections from the perspective of the WHOQOL. Br Schneider LC, Struening EL. SLOF: a behavioral rating scale J Psychiatry 1998;172:291-3. for assessing the mentally ill. Soc Work Res Abstr 1983 Fall;19:9-21. 8 Sabbag S, Twamley EM, Lea Vella MA. Assessing Everyday Functioning in Schizophrenia: Not all Informants Seem 18 Mucci A, Rucci P, Rocca P, et al. The Specific Level of Equally Informative. Schizophr Res 2011;131:250-5. Functioning Scale: construct validity, internal consistency 9 Barry MM, Zissi A. Quality of life as an outcome measure in and factor structure in a large Italian sample of people evaluating mental health services: a review of the empirical evi- with schizophrenia living in the community. Schizophr Res dence. Soc Psychiatry Psychiatr Epidemiol 1997;32:38-47. 2014;159:144-50. 10 Patterson TL, Semple SJ, Shaw WS, et al. Self-reported so- 19 Herdman M, Herdman J, Fox-Rushby X. A model of equiva- cial functioning among older patients with schizophrenia. lence in the cultural adaptation of HRQoL instruments: the Schizophr Res 1997;27:199-210. universalist approach. Qual Life Res 1998;7:323-35.

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Appendix A Specific level of functioning assessment and physical health inventory

INFORMAZIONI SUL VALUTATORE INFORMAZIONI SUL SOGGETTO Nome del valutatore: Nome del soggetto: ______(per cortesia in stampatello) Data di nascita: ______Posizione accademica del valutatore: ______Sesso: ¨ Maschio ¨ Femmina

Data in cui è stato compilato il questionario: Indirizzo: ______

Questa persona è in grado di parlare, leggere e comprendere l’italiano? ¨ Sì ¨ No

In caso di risposta negativa, quale lingua o adattamenti la persona solitamente richiede? ______(specificare)

Nelle pagine che seguono le sarà chiesto di formulare alcuni giudizi sulle capacità e abilità di questo individuo. Si prega di ricor- dare che le sue risposte dovrebbero riflettere ciò che è stato più caratteristico dell’individuo durante la scorsa settimana, il modo in cui l’individuo è stato per la maggior parte del tempo. Pertanto, la sua valutazione non si deve limitare solo a come stava l’individuo l’ultima volta in cui l’ha visto. Il suo punteggio si ripercuoterà sul servizio che questa persona riceverà, per cui è essenziale che si avvalga delle informazioni su come stava abitualmente l’individuo la settimana precedente.

Basi le sue risposte su come le persone di simili età, sesso e bagaglio culturale gestiscono queste attività nella normale vita quotidiana. Non usi il suo programma o struttura come unica base per il confronto. Siamo più interessati a come l’individuo si gestisce al di fuori del programma previsto per lui rispetto a come aderisce ad esso.

Utilizzi il buon senso. I seguenti item non sono tecnici o complessi, nel formulare la sua valutazione ricorra alle conoscenze in suo possesso. Questa valutazione è stata adattata dalla New Jersey Specific Level of Functioning e della New York Level of Care. Istruzioni: Verifichi quale numero meglio descrive il caratteristico livello di funzionamento del soggetto per ogni voce elencata sotto. Sia il più accurato possibile. Se non è sicuro rispetto ad un determinato punteggio, chieda a qualcuno che conosce il paziente o consulti la cartella clinica.

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Segni un solo numero per ogni voce, controlli di aver contrassegnato tutte le voci.

Cura di sé Crea problematiche, senza Minimo Limita in effetto sul effetto sul gran parte il Ostacola il Nessun funzionamento funzionamento funzionamento funzionamento A. Condizione fisica problema generale generale generale generale 1. VISTA 5 4 3 2 1 2. UDITO 5 4 3 2 1 3. COMPROMISSIONE DELL’ELOQUIO 5 4 3 2 1 4. DEAMBULAZIONE, USO DELLE GAMBE 5 4 3 2 1 5. UTILIZZO DI MANI E BRACCIA 5 4 3 2 1 Necessita di un suggerimento Necessita di un Necessita Totalmente verbale o di aiuto fisico o di un aiuto Totalmente B. Competenze nella cura di sé autosufficiente consigli di assistenza considerevole dipendente 6. ANDARE ALLA TOILETTE (usa corret- 5 4 3 2 1 tamente la toilette, mantiene puliti sé e lo spazio) 7. ALIMENTAZIONE 5 4 3 2 1 (utilizza gli utensili correttamente, abitu- dini alimentari) 8. IGIENE PERSONALE 5 4 3 2 1 (corpo e denti, pulizia generale) 9. VESTIRSI DA SOLI 5 4 3 2 1 (seleziona capi di abbigliamento ade- guatamente; si veste autonomamente) 10. CURA DELLA PROPRIA PERSONA 5 4 3 2 1 (capelli, trucco, aspetto generale) 11. CURA DEI PROPRI BENI 5 4 3 2 1 12. CURA DEL PROPRIO SPAZIO VITALE 5 4 3 2 1

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Funzionamento sociale Molto Generalmente caratteristico caratteristico Moderatamente Generalmente Molto atipico di questa di questa caratteristico di atipico per per questa C. Relazioni interpersonali persona persona questa persona questa persona persona 13. TOLLERA I CONTATTI CON GLI 5 4 3 2 1 ALTRI (non si allontana o respinge) 14. STABILISCE I CONTATTI CON GLI 5 4 3 2 1 ALTRI 15. COMUNICA IN MODO EFFICACE 5 4 3 2 1 (discorso e gestualità comprensibili e attinenti) 16. PARTECIPA ALLE ATTIVITÀ SENZA 5 4 3 2 1 SUGGERIMENTI 17. PARTECIPA A GRUPPI 5 4 3 2 1 18. ALLACCIA E MANTIENE LE AMICIZIE 5 4 3 2 1 19. CHIEDE AIUTO QUANDO 5 4 3 2 1 NECESSITA D. Accettabilità sociale Mai Raramente Qualche volta Di frequente Sempre 20. ABUSI VERBALI 5 4 3 2 1 21. ABUSI FISICI 5 4 3 2 1 22. DISTRUGGE BENI 5 4 3 2 1 23. È AGGRESSIVO FISICAMENTE 5 4 3 2 1 VERSO SE STESSO 24. HA PAURA, PIANGE, È APPICCICOSO 5 4 3 2 1 25. SI APPROPRIA DI BENI ALTRUI 5 4 3 2 1 SENZA AUTORIZZAZIONE 26. REITERA I COMPORTAMENTI 5 4 3 2 1 (passi, oscillazioni, rumori, ecc.)

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Competenze in ambito comunitario Necessita di Necessita di un Necessita Totalmente suggerimenti o aiuto fisico o di un aiuto Totalmente E. Attività autosufficiente consigli verbali di assistenza sostanziale dipendente 27. RESPONSABILITÀ DOMESTICHE 5 4 3 2 1 (pulizia della casa, cucinare, lavare vestiti, ecc.) 28. ACQUISTI 5 4 3 2 1 (selezione di articoli, scelta di negozi, pagamento di cassa) 29. GESTIONE DELLE PROPRIE FINANZE 5 4 3 2 1 (gestione del budget, pagamento delle bollette) 30. USO DEL TELEFONO 5 4 3 2 1 (trovare il numero, digitare il numero, conversazione, ascolto) 31.ALLONTANAMENTO DALLA 5 4 3 2 1 PROPRIA ABITAZIONE SENZA PERDERSI 32. UTILIZZO DEI TRASPORTI PUBBLICI 5 4 3 2 1 (selezionare percorso, usare gli orari, pagare tariffe, effettuare i trasferimenti) 33. IMPIEGO DEL TEMPO LIBERO 5 4 3 2 1 (letture, visite agli amici, ascoltare musica, ecc.) 34. RICONOSCERE ED EVITARE 5 4 3 2 1 PERICOLI COMUNI (traffico, incendio, ecc.) 35.AUTOMEDICAZIONE 5 4 3 2 1 (comprendere lo scopo, assumere come prescritto, riconoscere gli effetti collaterali) 36. UTILIZZO DEI SERVIZI MEDICI E 5 4 3 2 1 DI COMUNITÀ (sapere a chi rivolgersi, come e quando usarli) 37. LETTURA DI BASE, SCRITTURA E 5 4 3 2 1 CALCOLO (sufficiente per le necessità quotidiane) Molto Generalmente caratteristico caratteristico Moderatamente Generalmente Molto atipico di questa di questa caratteristico di atipico per per questa F. Capacità lavorative persona persona questa persona questa persona persona 38. POSSIEDE COMPETENZE LAVORATIVE 5 4 3 2 1 39. LAVORA CON UNA SUPERVISIONE 5 4 3 2 1 MINIMA 40. SOSTIENE GLI SFORZI LAVORATIVI 5 4 3 2 1 (non si distrae facilmente, è capace di lavorare sotto stress) 41. SI PRESENTA AGLI APPUNTAMEN- 5 4 3 2 1 TI PUNTUALE 42. SEGUE ACCURATAMENTE LE 5 4 3 2 1 ISTRUZIONI VERBALI 43. COMPLETA I COMPITI ASSEGNATI 5 4 3 2 1

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Altre informazioni 44. In base alla conoscenza di questa persona, ci sono altre abilità o aree problematiche non contemplate da questo questionario e rilevanti ai fini della capacità di questa persona di operare in modo indipendente? Se è così, si prega di specificare. ______

45. Quanto bene conosce le capacità e il comportamento della persona che ha appena valutato? (Barrare una casella) MOLTO BENE ABBASTANZA BENE PER NULLA 5 4 3 2 1 46. Ha discusso questa valutazione con il soggetto? (Barrare una casella) ¨ Sì ¨ No Se SÌ, l’individuo concorda generalmente con la valutazione? (Barrare una casella) ¨ Sì ¨ No Se NO, si prega di commentare ______

Firma del valutatore ______

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Stato di salute fisica Istruzioni: Metta una X in tutte le caselle che descrivono il soggetto. Problema attuale di salute fisica dell’individuo Quali delle seguenti opzioni descrive meglio la deambulazione dell’individuo ❏❏Nessuno ❏❏Completamente indipendente ❏❏Arteriosclerosi cardiaca ❏❏Usa un bastone o un deambulatore ❏❏Ipertensione ❏❏Instabile ❏❏Altro disturbo circolatorio ❏❏Cammina solo con l’assistenza del personale ❏❏Gravi problemi respiratori ❏❏Diabete Uso della sedia a rotelle ❏❏Obesità ❏❏Indipendente ❏❏Artrite ❏❏Sta sulla sedia a rotelle o necessita di un supporto ❏❏Ulcera da decubito (piaghe da decubito) ❏❏Deve essere spinto ❏❏Crisi convulsive (epilessia) ❏❏Sta a letto ❏❏Disturbo gastro-intestinale ❏❏Sindrome organica cerebrale Cura della propria persona ❏❏Evento cerebrovascolare- Stroke ❏❏Deficit visivi Fare il bagno: ❏❏Cecità ❏❏Completamente indipendente ❏❏Compromissione dell’udito ❏❏Ha bisogno di solleciti ❏❏Compromissione del linguaggio ❏❏Ha bisogno di supervisione ❏❏Frattura ❏❏Ha bisogno di moderata assistenza fisica ❏❏Disturbo uro-genitale ❏❏Ha bisogno di molta assistenza fisica ❏❏M. di Huntington ❏❏Ha bisogno di una cura completa ❏❏M. di Alzheimer ❏❏M. di Parkinson Vestirsi: ❏❏Discinesia tardiva ❏❏Completamente indipendente ❏❏Malattia neoplastica ❏❏Ha bisogno di solleciti ❏❏Altro ❏❏Ha bisogno di supervisione ❏❏Ha bisogno di moderata assistenza fisica Sussidi (per la salute fisica) usati o richiesti dal singolo ❏❏Ha bisogno di molta assistenza fisica ❏❏Nessuno ❏❏Ha bisogno di una cura completa ❏❏Occhiali ❏❏Protesi uditive Prepararsi: ❏❏Dentiera ❏❏Completamente indipendente ❏❏Altro ❏❏Ha bisogno di solleciti ❏❏Ha bisogno di supervisione Procedure qualificate di cura richieste dall’individuo ❏❏Ha bisogno di moderata assistenza fisica ❏❏Nessuna ❏❏Ha bisogno di molta assistenza fisica ❏❏Valutazione quotidiana segni vitali ❏❏Ha bisogno di una cura completa ❏❏Trattamento insulinico ❏❏Prevenzione delle piaghe da decubito Mangiare: ❏❏Trattamento delle ulcere da decubito ❏❏Completamente indipendente ❏❏Gestione di catetere/stomia ❏❏Ha bisogno di solleciti ❏❏Mantenimento delle condizioni di asepsi mediante abbigliamento idoneo ❏❏Ha bisogno di supervisione ❏❏Fisioterapia ❏❏Ha bisogno di moderata assistenza fisica ❏❏Fisioterapia riabilitativa per l’incontinenza ❏❏Ha bisogno di molta assistenza fisica ❏❏Irrigazione della lesione ❏❏Ha bisogno di una cura completa ❏❏Aspirazione secrezioni ❏❏Terapia inalatorie Usare il bagno: ❏❏Nutrizione parenterale ❏❏Completamente indipendente ❏❏Nutrizione enterale ❏❏Ha bisogno di solleciti ❏❏Altro ❏❏Ha bisogno di supervisione ❏❏Ha bisogno di moderata assistenza fisica Incontinenza urinaria ❏❏Ha bisogno di molta assistenza fisica ❏❏Mai ❏❏Ha bisogno di una cura completa ❏❏Meno di una volta al giorno ❏❏Solo notturna Commenti: ❏❏1-3 volte al giorno (Specifichi e descriva le aree che richiedono una valutazione al fine di determi- ❏❏Più di 3 volte al giorno nare il grado di assistenza che l’individuo necessita) ❏❏Uso del catetere ______Incontinenza fecale ______❏❏Mai ______❏❏Meno di una volta al giorno ❏❏Una volta al giorno ❏❏Più di una volta al giorno ❏❏Portatore di colonstomia Firma del valutatore ______

Titolo accademico ______

Data di compilazione ______

296 Assessment and instruments in psychopathology

Autism Rating Scale (ARS) – Italian version Scala di Valutazione dell’autismo – versione italiana

M. Ballerini1, G. Stanghellini2,3, M. Chieffi4, P. Bucci4, P. Punzo4, G. Ferrante4, N. Merlotti4, A. Mucci4, S. Galderisi4 1 Department of Mental Health, Florence, Italy; 2 “G. d’Annunzio” University, Chieti, Italy; 3 “D. Portales” University”, Santiago, Chile; 4 Department of Psychiatry, University of Naples SUN, Italy

Summary description of the instrument is reported. The procedures fol- The autism rating scale (ARS) is an instrument intended to inves- lowed for translation, adaptation and training of researchers are tigate the personal level of experience of individuals with schizo- described. Lastly, the results on inter-rater reliability are shown. phrenia in real-life social situations. It originates from previous qualitative analyses based on in-depth interviews with persons Key words with schizophrenia in clinical and research settings. The Italian Autism • Phenomenology • Psychopathology • Schizophrenia • Social adapted version of the ARS is herewith presented, and a brief dysfunction • Subjective experience

Introduction ment of “schizophrenic autism” may help to clarify one of the fundamental phenomena for the understanding of Impairment of social functioning is present in the majority schizophrenia. of patients with schizophrenia. It has been observed that Towards this aim, the autism rating scale (ARS) 13 has been such impairment is not a direct consequence of clinical developed to investigate the subjective experience of in- symptoms and that it influences the course and outcome dividuals with schizophrenia in real-world social encoun- 1 2 of the disease . The de-structuring of social life (Criterion ters by collecting soft phenomena that are traditionally B of DSMs) is considered a basic diagnostic characteristic not included in checklists. The scale originates from pre- 1 2 of the syndrome and has been hypothesised to represent vious qualitative analyses based on in-depth interviews 3-5 one of the fundamental phenomena of schizophrenia . with persons with schizophrenia in clinical and research Psychosocial dysfunction is a complex construct that is settings 14-18. The result has been a rich and detailed col- difficult to define and assess. It includes a variety of het- lection of patients’ self-descriptions related to emotional erogeneous domains, such as personal care, interpersonal attunement/disattunement, self-other demarcation/non- relationships, education and occupation. Moreover, func- demarcation, emotion recognition/non-recognition, emotional deficits are mainly considered in a behavioural per- tional/cognitive attitude towards others, endorsement/re- spective, and therefore assessed as a quantitative reduc- fusal of social norms, etc. The authors of the scale created tion in performance 6. a database using patients’ self-reports from which different In a phenomenological perspective, more specific char- categories were developed, based on structural similari- acterisation of the basic disturbance of social relations ties among social abnormal phenomena. On the basis of in schizophrenia has been proposed, with the introduc- these data, the original version of the scale was devel- tion of the concept of dis-sociality 6. This term underlines oped. It is a semi-structured interview including 16 dis- the qualitative alteration of social competence by going tinctive items grouped in 6 categories: hypo-attunement, beyond the strictly behavioural-functionalist perspec- invasiveness, emotional flooding, algorithmic conception tive. It reflects a disturbance of participation in social of sociality, antithetical attitude toward sociality and idi- life related to phenomena such as those included in the onomia. The interviewer should use the prompts selected concept of autism, e.g., the tendency to rumination not for each item to elicit spontaneous narratives. The patient’s oriented towards reality, rigid adherence to idiosyncratic narratives should be written verbatim. A detailed descrip- ideas, the emergence of a deviant hierarchy of values, tion of each category and item is provided in the interview aims and ambitions 7-9, as well as anomalies in attune- together with a list of examples consisting in sentences ment and common sense 10-12. Therefore, reliable assess- collected by patient interviews.

Correspondence Giovanni Stanghellini, DiSPUTer, “G. d’Annunzio” University, via dei Vestini 31, 66110 Chieti Scalo, Italy • E-mail: [email protected]

Journal of Psychopathology 2015;21:297-308 297 M. Ballerini et al.

The Italian version of the ARS is presented herewith. A nal one, a more common lexicon was adopted. The in- brief description of the instrument is reported, the pro- terview was organised in a more structured way by sug- cedures followed for translation and adaptations of the gesting 1 to 5 questions to explore each item; the positive interview are illustrated and the training of researchers, as answer to one of the suggested questions is sufficient to well as the results on reproducibility, are reported. consider that item fulfilled. The manual was enriched with the addition of some more Description of the ARS “related clinical manifestations” and more examples of sentences collected from the interviews conducted with The ARS assesses “What it is like” to be a person with Italian subjects. schizophrenic autism in the social world. It explores the The Italian version of ARS is attached in the appendix. subjective experience of inter-personal relationships, contacts and social situations in daily life in the last three Training of evaluators and assessment of inter- months. The scale focuses on all kinds of “real-life social rater reliability situations”, e.g. home, work, school, leisure, friendship, etc. Behaviours are also explored as they may be sug- One of the authors (MB) illustrated the final adapted Ital- gestive of qualitatively and quantitatively altered social ian version to the three evaluators. He conducted three experience, e.g. diminished social interests, interactions, interviews with patients affected by schizophrenia to be reduced interpersonal involvement, loss of naturalness used as training material. Over the following days, the in social contacts, refusal of interpersonal bonds, new or ARS was administered by the raters to 5 patients with unusual preoccupation with existential, metaphysical, re- a diagnosis of schizophrenia according to the DSM-IV. ligious, philosophical, or psychological themes, lack of They rotated in conduction of the interview, but all at- delicacy or tact in social contexts, etc. tributed an independent scoring. The ARS includes 16 distinctive items grouped in 6 cat- The inter-rater reliability (IRR) was formally evaluated by egories: hypo-attunement, invasiveness, emotional flood- calculating the intraclass correlation coefficient (ICC). Ex- ing, algorithmic conception of sociality, antithetical at- cellent agreement was observed among raters (ICC rang- titude toward sociality and idionomia. Severity is scored ing from 0.75 and 0.97) (Table I). by taking into account frequency, intensity of subjective The validation of the scale in a wider sample of patients arousal or distress, level of impairment and possibility to with schizophrenia was started and is still ongoing. cope. The interview takes from 30 to 60 minutes. References Translation and adaptation of the Italian 1 American Psychiatric Association. DSM-IV. Washington: version American Psychiatric Association 1994. The ARS was translated into Italian by two authors of the 2 American Psychiatric Association. DSM-IV-TR. Washington: original version (GS and MB), both native Italian speak- American Psychiatric Association 2000. ers. For this reason, the back-translation into English was 3 Maj M. Critique of the DSM-IV operational diagnostic crite- not performed. ria for schizophrenia. Br J Psychiatry 1998;172:458-60. The adaptation of the Italian version is the result of some 4 Lezenweger MF, Dworkin RH. The dimensions of schizo- meetings between the two Italian authors of the original phrenia phenomenology. Not one or two, at least three, per- version (GS and MB) and a group of researchers from haps four. Br J Psychiatry 1996;168:432-40. the Department of Psychiatry of the University of Naples 5 Strauss JS, Carpenter WT, Bartko J. The diagnosis and un- SUN including two expert senior psychiatrists (SG and derstanding of schizophrenia. III. Speculations on the pro- AM) and three evaluators: a young psychiatrist attending cess that underlies schizophrenic symptoms. Schizophr Bull a PhD course (MC) and two trainees in psychiatry (PP and 1974;11:61-75. GF), all with extensive experience in the administration 6 Stanghellini G, Ballerini M. Dis-sociality: the phenomeno- of clinical interviews and a solid background in psychological approach to social dysfunction in schizophrenia. pathology. In the first meeting, the authors illustrated the World Psychiatry 2002;1:102-6. first draft of the Italian version to the three evaluators and 7 Bleuler E. Dementia praecox oder gruppe der schizo- trained them on administration and scoring of the inter- phrenien. Leipzig: Deuticke 1911. view. During a further meeting, devoted to the discussion 8 Gundel H, Rudolf GAE. Schizophrenic autism. 2. Pro- of all observations arising from the administration of the posal for a nomothetic definition. Psychopathology questionnaire to 10 healthy controls and 6 patients with 1993;26:304-12. schizophrenia, several changes were made. 9 Minkowski E. La schizophrenie. Paris: Desclée de Brouwer In the Italian version of the scale, compared to the origi- 1927.

298 Autism Rating Scale

Table I. Results of Inter-rater reliability on the items of the Autism Rating Scale – Italian version. Risultati della riproducibilità tra valutatori per gli item della Scala di Valutazione dell’Autismo – versione italiana dell’Autism Rating Scale.

ARS – Autism Rating Scale ICC Hypo-attunement 1.1 Distance, detachment or lack of resonance 0.747 1.2 Inexplicability or incomprehensibility 0.856 1.3 Radical uniqueness and exceptionality 0.818 Invasiveness 2.1 Immediate feeling of hostility or oppression coming from the others 0.815 2.2 Immediate feeling of lack of self/other boundaries 0.977 2.3 Hyper-empathic experiences 0.981 Emotional flooding 3.1 Emotional paroxysms in front of others 0.941 3.2 Coenesthetic paroxysms in front of others 0.750 Algorithmic conception of sociality 4.1 Observational – ethologically oriented –attitude 0.944 4.2 Pragmatic – need-for-interplay oriented –attitude 0.922 4.3 Speculative – theoretically oriented – attitude 0.749 Antithetical attitude toward sociality 5.1 Antagonomia as refuse of social shared knowledge and assumptions 0.959 5.2 Antagonomia as distrust toward attunement with others 0.887 5.3 Abstract idealization 0.909 Idionomia 6.1 Charismatic Concerns 0.960 6.2 Metaphysical Concerns 0.761

10 Blankenburg W. Der verlust der naturalichen selbverstan- 15 Stanghellini G, Ballerini M. Values in persons with schizo- dlickeit. Stuttgart: Enke 1971. phrenia. Schizophr Bull 2007;33:131-41. 11 Parnas J. The Core Gestalt of Schizophrenia. World Psychia- 16 Lysaker PH, Carcione A, Dimaggio G, et al. Metacognition try 2012;11:67-9. amidst narratives of self and illness in schizophrenia: associ- 12 Stanghellini G. Psicopatologia del senso comune. Milano: ations with insight, neurocognition, symptom and function. Raffaello Cortina Editore 2008. Acta Psychiatr Scand 2005;112:64-71. 13 Stanghellini G, Ballerini M, Lysaker PH. Autism rating scale. 17 Lysaker PH, Davis LW, Lysaker JT. Enactment in schizophre- J of Psychopatol 2014;20:273-285. nia: capacity for dialogue and the experience of the inability to commit to action. Psychiatry 2006;69:81-93. 14 Stanghellini G, Ballerini M. What is it like to be a person with schizophrenia in the social world? A first-person per- 18 Lysaker PH, Bob P, Pec O, et al. Metacognition as a link spective study on schizophrenic dissociality – Part 2: meth- which connects brain to behavior in schizophrenia. Transla- odological issues and empirical findings. Psychopathology tional Neuroscience 2013;4:368-77. 2011;44:183-92.

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Appendice Domandi generali introduttive Scala di Valutazione dell’Autismo – versione Puoi dirmi quanto tempo hai passato con le persone durante l’ul- italiana dell’Autism Rating Scale timo mese? Che genere di cose hai fatto con loro? Chi: Pazienti con schizofrenia, o con sospetto di schizofrenia, Cosa pensi degli altri? Sei interessato agli altri? o con disturbi dello spettro schizofrenico. Che significa per te stare con altre persone? Questa scala può contribuire a discriminare la schizofrenia da Ti sembra di avere difficoltà nello stare nel mondo insieme alle altre psicosi, e i disturbi di personalità del Cluster A da altri altre persone? disturbi di personalità. Ti senti come loro? Inoltre, può contribuire a definire caratteristiche cliniche di Ti sembra che le persone diano un po’ per scontate fatti e situa- pazienti affetti da Clinical High-Risk o Ultra High-Risk syn- zioni che per te non lo sono affatto? dromes. Ti sembra che a te succedano cose che agli altri non succedono? Per completare la valutazione il paziente deve essere com- pliant, motivato, e provvisto di sufficienti abilità linguistiche ed atteggiamento introspettivo. Intervista Cosa: Questa scala valuta “cosa si prova” a essere una persona Sensazione Ego-Sintonica di Radicale Unicità con schizofrenia (o con vulnerabilità alla schizofrenia) e stare ed Eccezionalità (A1.3) nel mondo sociale. Esplora l’esperienza soggettiva di relazioni inter-personali, 1.1 Ognuno di noi si sente un po’ particolare, diverso dagli altri, contatti, situazioni sociali così come si presentano ai pazienti ma a te capita di sentirti veramente unico, proprio diverso da nella vita quotidiana. tutti gli altri? Dove: Questa scala si focalizza su tutti i tipi di “situazioni Come se tu fossi di un altro tipo, di un’altra specie, proveniente da un’altra dimensione, da un altro pianeta, o addirittura quasi sociali di vita reale”, ad es. casa, lavoro, scuola, tempo libero, non umano? amicizia, incontri casuali, negozi, uffici, ecc. Hai la sensazione, per come sei, di rappresentare una sorta di Quando: Questa scala valuta queste caratteristiche durante i eccezione tra tutte le altre persone? tre mesi precedenti l’intervista. Se positiva andare direttamente al 2.1 se negativa procedere Come: L’intervistatore può servirsi dei suggerimenti selezio- con le successive. nati per ogni item in modo da suscitare narrazioni spontanee. 1.2 Ti senti abbastanza diverso da tutte le altre persone? Noti Le risposte del paziente dovrebbero essere trascritte parola per che c’è una certa diversità tra te e gli altri? parola. Per esempio per il tipo di cose che ti sono successe, per il tipo Nota: i pazienti utilizzano spesso metafore per illustrare le lo- di sensazioni che provi o che hai provato, per le tue idee par- ro esperienze soggettive. ticolari. Anche i comportamenti dovrebbero essere esplorati con do- Per il tuo modo di vedere il mondo e la vita in generale, per le mande specifiche poiché alcuni comportamenti sono sugge- cose che ti interessano, per come dai importanza e valore alle stivi di alterata esperienza della socialità. cose che ti succedono ed alle situazioni in cui ti trovi. Considera ad es. diminuzione degli interessi e delle interazioni sociali, rifiuto di sperimentare nuovi contatti e attività, Rifiuto di conoscenze e di assunti socialmente ridotte relazioni strette, ridotto coinvolgimento interpersonale, abbandono di attività precedentemente investite, perdita condivisi (Antagonomia) (A5.1) di naturalezza nei contatti sociali, rifiuto di legami interper- 2.1 Ti capita di provare fastidio, diffidenza, o addirittura ripu- sonali, nuova o inusuale preoccupazione o interesse riguardo gnanza per il modo comune di essere, di pensare, di compor- temi esistenziali, metafisici, religiosi, filosofici o psicologici, tarsi, di comunicare? ingenuità sociale, mancanza di delicatezza o tatto nei contesti Se positiva andare direttamente al 3.1 se negativa procedere sociali, ecc. con le successive. Per ogni item sono riportate manifestazioni associate, sugge- 2.2 Ti sembra di non riconoscerti nel modo in cui tutte le altre stive della presenza del fenomeno riportato nell’item specifi- persone pensano ? co. In alcuni casi il paziente può riferire le sole manifestazioni Nel modo in cui le persone abitualmente comunicano, come associate. In questo caso è opportuno rivolgere direttamente usano le parole? una domanda specifica che valuti la presenza del fenomeno Come danno valore e significato a fatti, avvenimenti, situazioni codificato nel singolo item. del mondo e della vita? Nelle cose in cui le persone mostrano di credere, cioè in quelle Come presentare al paziente la scala che sono le conoscenze a disposizione di tutti e da tutti date di valutazione per scontate? In quelle che sono le regole sociali comunemente accettate? Ti faremo alcune domande per capire meglio come ti trovi Ti senti poco motivato da quelli che sono gli obiettivi e le am- quando sei a contatto con gli altri nella vita di tutti giorni e quali bizioni che in genere mostrano di avere tutte o quasi tutte le sono le cose che ti interessano di più in generale. persone (es. un lavoro ben retribuito, una bella automobile, una casa di pregio, molti amici, vacanze)?

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Antagonomia: diffidenza verso la sintonizzazione poca delicatezza nelle situazioni sociali, poco tatto, poca sen- con gli altri (A5.2) sibilità, poco “savoir faire”? 3.1 Nella vita di tutti i giorni vuoi o devi prendere le distanze dalle altre persone e startene per conto tuo, fatta eccezione per Idealizzazione astratta (A5.3) i tuoi familiari o pochissime persone di tua fiducia? Anche se sei di indole solitaria, ti senti molto preso da ideali Se positiva andare direttamente al 4.1 se negativa procedere umanitari come la pace nel mondo, la giustizia, la fratellan- con le successive. za universale, il valore assoluto dell’amicizia, l’integrazione di 3.2 Ti mette imbarazzo o ti dà proprio fastidio avere relazioni razze, culture e religioni diverse? molto strette, intime, personali? Condividere con gli altri la tua sfera personale, le tue idee, le Atteggiamento Algoritmico Osservazionale tue emozioni, i tuoi sentimenti ed i lati più intimi? (etologico) (A4.1) Rifiuti anche solo l’idea di avere relazioni strette con le altre 7.1 Ti interessa osservare da vicino quello che succede quando persone, eccettuati i tuoi familiari? le persone interagiscono tra di loro per capire le regole ed il 3.4 Ti senti a disagio quando gli altri (eccettuati i familiari) si meccanismo delle diverse situazioni della vita quotidiana? (es. mostrano troppo interessati a te? persone in un ufficio pubblico, al bar, in un negozio, giovani 3.5 Stare abbastanza spesso insieme agli altri potrebbe causare la perdita della tua identità? che si ritrovano davanti ad un locale, ecc.). O farti Identificare in modo pericoloso con loro? Se positiva andare direttamente a 8.1 se negativa procedere con O farti perdere i tuoi pensieri originali? le successive. 7.2 Sei incuriosito dal modo di vivere delle altre persone tanto Sensazione immediata di Distanza, Distacco da passare del tempo ad osservarne i comportamenti? Senti la necessità di osservare da vicino i comportamenti degli o Mancanza di Risonanza (A1.1) altri e di dover fare uno sforzo per comprenderli, per capirne il 4.1 Quando sei con gli altri ti capita di avere una sensazione meccanismo, le regole di fondo, i principi di base? di distacco, di distanza, come se ci fosse una separazione, una barriera, un filtro, un velo tra te e gli altri? Atteggiamento Algoritmico Pragmatico (orientato Se positiva andare direttamente al 5.1 se negativa procedere verso la necessità di riuscire nell’interazione) con le successive. (A4.2) 4.2 C’è poca sintonia tra te e gli altri? Ti capita di non riuscire ad unirti, a legarti, ad “associarti” con 8.1 Ti capita di osservare con attenzione che cosa fanno gli altri gli altri? per imparare il comportamento o le “mosse giuste”, cioè cosa fa- Ti sembra di essere poco coinvolto, motivato, toccato, attratto o re e come regolarsi nelle diverse situazioni della vita quotidiana? stimolato dallo stare con gli altri? Se positiva andare direttamente a 9.1 se negativa procedere con Ti sembra di avere poca fluidità, di essere poco spontaneo le successive. quando interagisci con gli altri? 8.2 Ti capita di studiare come si comportano le altre persone 4.3 Nelle diverse situazioni della vita quotidiana, quando sei ad nelle diverse situazione della vita quotidiana al fine di poterle esempio in un luogo pubblico (in un ufficio, in un negozio, in imitare? un bar, sull’autobus …) hai la sensazione di essere poco presen- 8.3 Ti capita di studiare libri, giornali o riviste, o di seguire pro- te, di non riuscire a starci in modo naturale, di non partecipare grammi televisivi per mettere a punto un metodo o delle proce- in modo normale a quello che succede? dure per gestire le relazioni interpersonali e le diverse situazioni 4.4 Ti sembra che le persone in genere o le diverse situazioni sociali? della vita quotidiana, siano in qualche modo poco naturali ? 8.4 Hai per caso trovato un metodo personale, un modo tutto tuo, dei “trucchi”o le “mosse giuste” per regolarti e sapere cosa Sensazione immediata di Inesplicabilità fare nelle diverse situazioni della vita quotidiana? o Incomprensibilità (A1,2) 8.5 Quando sei a contatto con gli altri ti accorgi di dover pensare con attenzione a tutto quello che fai e come lo fai mentre 5.1 è per te un problema capire cosa abbiamo in testa gli altri ? gli altri sembrano muoversi in modo naturale? Se positiva andare direttamente al 6.1 se negativa procedere con le successive. Atteggiamento Algoritmico Teoretico (orientato 5.2 Ti sembra di avere difficoltà nel cogliere le intenzioni, i bisogni, i desideri le emozioni delle altre persone? ai principi) (A4.3) Hai difficoltà a capire al volo quello che succede in una situa- 9.1 Leggi libri, giornali, riviste o segui programmi televisivi poi- zione particolare come a scuola, al bar, ecc.? ché hai interesse a cercare di capire come si comporta la gente? Ti capita spesso la sensazione che gli eventi e ciò che accade A comprendere quali siano i meccanismi di fondo che regolano nella vita sociale sia difficile, poco comprensibile o addirittura il comportamento degli uomini ed i rapporti sociali in genere? enigmatico? Se positiva andare direttamente a 10.1 se negativa procedere 5.3 Soprattutto quando ti trovi in posti nuovi è un problema per con la successiva. te comprendere quelle che sono le regole di fondo ed avere 9.2 Rivolgi molte domande a persone di tua fiducia per capire un’immagine d’insieme di quello che succede? come si svolge la loro vita e come si comportano nelle diverse Ti accorgi o ti viene detto spesso di avere poca dimestichezza o situazioni personali e sociali?

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Idionomia: Interesse metafisico (A6.2) Parossismo Emotivo Inter-Personale (A3.1) 10.1 Sei insoddisfatto del modo in cui le altre persone danno 13.1 Ti capita mai di sentirti sovraccaricato dalle tue emozioni per scontati fatti eventi oggetti del mondo prendendoli così co- quando sei con gli altri anche in situazioni comuni della vita di me appaiono? tutti i giorni (es. per la strada, in un bar affollato, al supermerca- Ti senti fortemente attratto dalla complessità dell’esistenza, del to, nell’autobus, ad una stazione etc)? mondo, della realtà o della vita in generale ? In queste situazioni ti prende ansia, o paura, rabbia, tensione Se positiva andare direttamente a 11.1 se negativa procedere interna o nervosismo incontrollabile? con le successive. Quando sei in luoghi pubblici a contatto con altre persone ti pren- 10.2 Sei attirato dalla ricerca di cosa ci sia davvero dietro le dono fastidiose sensazioni corporee come tensione muscolare, ri- semplici apparenze? (come sia fatta veramente la realtà, di qua- gidità, tremore, tachicardia, sudorazione o altri sintomi fisici? le sia la vera essenza,di come è possibile percepire ed entrare in contatto con il mondo)? Parossismo Dis-Estesico Interpersonale (A3.2) Ti affascina, o oppure ti senti costretto a leggere, studiare, argo- 14.1 Ti succede, quando sei in mezzo alle persone, di sentire menti di tipo scientifico, filosofico o religioso per capire cosa dentro di te strane sensazioni, spesso spiacevoli o inquietanti? sia veramente la realtà? Come vibrazioni, energie o forze sconosciute? 10.3 Ti capita di sviluppare a proposito di questi argomenti idee O che all’interno del tuo corpo si verifichino strani movimenti? personali che vanno anche parecchio oltre quello che trovi Oppure di sentirti tutto o in parte bloccato? scritto sui libri o che è sostenuto da gruppi organizzati? Ti capita di avere la sensazione che parti del tuo corpo si trasfor- mino o di avvertire la presenza di parti del corpo che solitamen- Sensazione immediata di Ostilità od Oppressione te non si riescono a percepire? proveniente dagli altri (A2.1) 11.1 Quando ti trovi in pubblico ti capita di sentirti, in qualche Esperienze Iper-Empatiche (A2.3) modo, esposto, passivo, alla mercé degli altri? 15.1 Quando una persona ti racconta qualcosa di quello che gli Se positiva andare direttamente a 12.1 se negativa procedere è successo ti capita di avere la sensazione di perdere i confini con le successive. che ti separano dall’altro? 11.2 Ti capita( di sentirti al centro del mondo?) Di avere la Se positiva andare direttamente a 16.1 se negativa procedere percezione che le cose che accadono (siano in qualche modo con le successive. lì per te? Che) abbiano a che fare con te? Che ti riguardino? 15.2 Ti capita quando sei con altre persone di (immedesimarti Anche le cose che non sembrano apparentemente in relazione in loro a tal punto da) sentirti fuso con gli altri? Come se foste con te? una sola cosa? 11.3 Quando ti trovi in pubblico ti capita di sentirti in una si- 15.3 Ti succede di sentire che i tuoi pensieri siano fusi con quel- tuazione di pericolo immediato, come se tu fossi vulnerabile ? li dell’altro? Di percepire da loro ostilità, minaccia, cattive intenzioni, di es- Ti capita di riuscire a leggere i pensieri dell’altro come se fos- sere guardato male anche se non riesci a spiegartene il motivo? sero i tuoi? Di sentirti oppresso, risucchiato inondato o sommerso dagli altri anche senza un motivo apparente? Idionomia: Orientamento Carismatico (A6.1) Sensazione immediata di mancanza di confini Sé/ 16.1 Ti è capitato di ricevere qualcosa come una rivelazione molto particolare o di aver avuto un’ illuminazione profonda ? Altro da Sé (A2,2) Ti sei stupito di aver scoperto qualcosa di veramente importante 12.1 Quando ti trovi in mezzo agli altri ti capita di avere la per il destino tuo e delle altre persone? sensazione di essere Se positiva terminare l’intervista se negativa procedere con le super-sensibile, come senza pelle, senza barriere, o come se tu successive. avessi dei buchi, o come se tu fossi trasparente? 16.2 Ti sei accorto di essere dotato di caratteristiche particolari Se positiva andare direttamente a 13.1 se negativa procedere o facoltà che le altre persone non hanno? con le successive. Qualcosa di tipo mistico spirituale, o religioso? 12.2 Gli sguardi delle altre persone ti danno noia come se tu Oppure qualcosa di tipo scientifico o filosofico? fossi toccato, ferito, bucato? La capacità di capire la realtà in modo più profondo? I gesti, le azioni degli altri ti danno la sensazione di colpirti La possibilità di controllare fatti o situazioni della vita? fisicamente, come se entrassero dentro di te? Come se ti pene- Oppure la dotazione di poter comunicare in modo speciale? trassero? Oppure uno speciale senso per l’arte e la creatività? Se qualcuno ti rivolge la parola, magari all’improvviso, hai la 16.3 Hai provato a far parte di gruppi politici religiosi mistici o sensazione di essere quasi toccato fisicamente da quello che ti filosofici ma sei rimasto poco soddisfatto da come funzionano? dice anche se il contenuto non è offensivo o minaccioso ? 16.4 Ti è stata data o hai capito di avere una missione molto 12.3 Quando sei in mezzo alle persone ti capita di sentirti inva- speciale da compiere? so o trapassato anche senza contatti fisici? Ti senti in qualche modo chiamato o prescelto per un compito o 12.4 Ti è mai capitato di sentirti come penetrato, invaso fisica- qualcosa di molto importante da svolgere, per esempio la lotta mente quando vieni toccato da qualcuno o quando vieni ab- tra il bene e il male, la giustizia, importanti scoperte scientifi- bracciato? che, filosofiche o religiose?

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Intensità Nome: ______soggettiva Frequenza Impairment Coping di arousal Codice: ______Autism Rating Scale o distress Classificare in: (1) assente; (2) minimo; (3) lieve; (4) moderato; GG/MM/AAAA: _____/______/______(5) moderatamente grave; (6) grave; (7) molto grave A1. Ipo - 1.1 Sensazione Sensazione immediata di distanza e distac- Sintonizzazione immediata co, un senso di barriera tra sé e gli altri. di Distanza, Sensazione immediata di non avere coin- Distacco o volgimento naturale e spontaneo, oppure Mancanza di lamentele di non sentirsi propriamente pre- risonanza senti nel mondo sociale. I pazienti possono lamentarsi dell’assenza di naturalezza del mondo e delle altre persone. Talvolta viene manifestata come mancanza di risonanza, come un senso pervasivo di non essere coinvolto, incitato, mosso, motivato, tocca- to, attratto o stimolato dal mondo esterno e dagli altri. 1.2 Sensazione Incapacità ad afferrare o decifrare le inten- immediata di zioni, le emozioni, le credenze, i desideri o Inesplicabilità o i bisogni delle altre persone. Difficoltà o in- Incomprensibilità capacità di cogliere intuitivamente il valore e il significato delle situazioni sociali, di afferrare in modo pre-riflessivo e automatico il valore e il significato di eventi, questioni, o situazioni della vita quotidiana e di cogliere le regole implicite che caratterizzano specifici contesti sociali oppure ruoli sociali definiti nel corso dei rapporti interpersonali. I pazienti possono lamentare un senso di enigmaticità e incomprensibilità del mondo interpersonale che può essere avvertito come difficile o ostile, possono lamentare una perdita di naturalezza nei contatti sociali, ridurre i contatti sociali, rifiutarsi di sperimentare nuove e attività, ecc.. I pazienti possono mostrare mancanza di “tatto”, di “savoir faire”, di delicatezza nei contesti sociali, ecc.. 1.3 Sensazione Ego Esaltazione ego-sintonica del proprio sen- - Sintonica di timento di radicale unicità ed eccezionali- Radicale Unicità tà. A volte è rivendicata come una scelta ed Eccezionalità libera, l’effetto di un “diverso volere”. Altre volte è sentito come un destino e non come una scelta deliberata. La rivendicazione di essere “radicalmente diverso dalle altre persone”(categoria 1) può fondarsi su una profonda metamorfosi della coscienza di sé pre-riflessiva, derivando dalla presenza nel proprio psichismo di sensazioni e pensieri anomali e inconsueti, o avvertiti come non propri, di sensazioni di disconnessione dalla realtà comunemente condivisa, e di esperienze solipsistiche.

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Intensità Nome: ______soggettiva Frequenza Impairment Coping di arousal Codice: ______Autism Rating Scale o distress Classificare in: (1) assente; (2) minimo; (3) lieve; (4) moderato; GG/MM/AAAA: _____/______/______(5) moderatamente grave; (6) grave; (7) molto grave A2. Invasività 2.1 Sensazione Sensazione immediata di essere, in qualche immediata modo, invasi, minacciati sommersi, trapas- di Ostilità od sati, inondati, costretti, dal mondo esterno Oppressione o dalle altre persone. proveniente dagli Sensazione immediata di trovarsi in qual- altri che modo in una posizione passiva, perico- losamente esposta, alla mercé del mondo, o delle altre persone. I pazienti possono lamentare ostilità da parte del mondo esterno senza saperne spie- gare i motivi. La sensazione immediata e opprimente di essere al centro del mondo (auto-referen- zialità, o esperienza di centralità). 2.2 Sensazione Sensazione immediata di essere in qualche immediate di modo “ aperti, spalancati o trasparenti”, o mancanza dei di avere incredibilmente una “pelle sottile”, confini sé/altro senza “barriere”, ecc. da sé Sensazione immediata di essere fisicamente invasi o penetrati dai gesti, dalle parole, dalle azioni e dagli sguardi delle altre persone. I pazienti possono manifestare sensazioni di ansia o disagio quando si trovano di fronte, in contatto o toccati fisicamente da qualcuno (anche da una persona ben conosciuta o da un parente), oppure anche quando vengono abbracciati. 2.3 Esperienze Incapacità di prendere le distanze dalle al- iper - empatiche tre persone determinata da sensazioni immediate di fusione con loro, iper-empatia, lettura diretta della mente degli altri, esperienze mimetiche o fusionali dove i propri fenomeni mentali sono mescolati a quelli degli altri. I pazienti a volte evitano situazioni sociali perché in esse capita loro di sentirsi “fon- dere” con gli altri. Talora sono esaltati dalla loro capacità di entrare in sintonia diretta con la mente degli altri, oppure possono vivere tali esperienze con perplessità, o ansia.

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Intensità Nome: ______soggettiva Frequenza Impairment Coping di arousal Codice: ______Autism Rating Scale o distress Classificare in: (1) assente; (2) minimo; (3) lieve; (4) moderato; GG/MM/AAAA: _____/______/______(5) moderatamente grave; (6) grave; (7) molto grave A4. Concezione 4.1 Atteggiamento Tentativo di dare un senso agli stati men- algoritmica della algoritmico tali degli altri che si celano dietro il lo- socialità osservazionale ro comportamento e il comportamento (etologico) umano in generale e/o di comprendere il significato delle situazioni sociali attraverso osservazioni empiriche delle altre persone nelle comuni operazioni della vita. 4.1.1 Atteggiamento Tentativo di sviluppare un metodo espli- algoritmico cito o costruire un personale algoritmo pragmatico il cui scopo è partecipare a specifiche (orientato verso situazioni o interazioni sociali. I pazienti la necessità cercano di entrare in contatto con altre di riuscire persone e si occupano di imparare a inte- nell’interazione) ragire efficacemente con gli altri. A volte questi tentativi sono condotti tramite analisi “scientifiche” o “filosofiche”, ricerche sistematiche, ricorrenti e pervasive, studi personali e approfondimenti. Questi tentativi possono apparire idiosincrasici, iper-elaborati e non propriamente idonei al valore, al significato reale e alle moda- lità di specifiche relazioni interpersonali e situazioni sociali. 4.1.2 Atteggiamento Interesse teorico e puramente concettuale Algoritmico nei confronti del fenomeno della sociali- Teoretico tà e possibilmente verso tutta la realtà e (orientato ai verso il fenomeno complesso della vita principi) sulla terra. I pazienti sono più interessati a scoprire i principi di fondo che alla loro utilità pratica o alla loro applicazione. I pazienti sono interessati a scoprire i meccanismi esatti che regolano la relazione sé-mondo attraverso studio e letture, spesso non sistematiche e senza adottare la metodologia delle discipline considerate, oppure attraverso compulsive riflessioni, letture, analisi, speculazioni.

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Intensità Nome: ______soggettiva Frequenza Impairment Coping di arousal Codice: ______Autism Rating Scale o distress Classificare in: (1) assente; (2) minimo; (3) lieve; (4) moderato; GG/MM/AAAA: _____/______/______(5) moderatamente grave; (6) grave; (7) molto grave A5. 5.1 Antagonomia Atteggiamento scettico e fortemente dubi- Atteggiamento come rifiuto di tativo riguardo agli assunti del senso comu- antitetico verso conoscenze, ne e/o della conoscenza convenzionale, la socialità assunti, sapere e/o dei valori e delle regole socialmente socialmente condivisi con lo sforzo di sospenderne il condiviso valore mettendoli tra parentesi. Ripugnanza esplicita per il modo comune di essere, di pensare e di comportarsi, rifiu- to sprezzante per il modo comune di dare per scontata la realtà assumendo come tali i fatti, gli eventi e gli oggetti del mondo. I pazienti scelgono di allontanarsi dal significato delle regole convenzionali, valori e credenze del senso comune e cercano di assumere una posizione eccentrica relati- vamente agli assunti comunemente condivisi. In alcuni casi lo scetticismo comporta un atteggiamento critico verso la semantica convenzionale: principalmente criticano le convenzionali associazioni oggetto-significato e tentano di elaborare strumenti mi- gliori per esprimere le proprie esperienze spesso idiosincrasiche. 5.2 Antagonomia Senso complessivo di diffidenza nei con- come diffidenza fronti dello stare in sintonia emotivo-affetti- verso la va con le altre persone. Rifiuto di relazioni sintonizzazione interpersonali strette, intime. con gli altri Scelta deliberata di prendere le distanze dagli altri così come si presentano nel “qui ed ora” della vita di tutti i giorni. I rapporti immediati (empatici) e i legami interpersonali sono respinti ed è particolarmente temuta la tendenza ad identificarsi con gli altri. Il contatto con le altre persone può essere sentito come una pericolosa fonte di perdita d’identità, di individuazione, di pensiero originale. 5.3 Idealizzazione Sostenere un’ideologia spiritualmente o astratta intellettualmente utopistica, distaccata dal concreto e quotidiano contatto interpersonale. L’impegno con le singole persone in carne ed ossa viene sostituito da un interesse verso l’intera umanità o astratti valori umanitari. I pazienti possono rilasciare dichiarazioni che appaiono in contrasto con il loro stile di vita, generalmente appartato e solitario. Gli ideali umanitari possono apparire idiosincrasici oppure possono rappresentare un’estremizzazione di valori altrimenti condivisi da altri individui o gruppi di individui (religiosi, politici, ecc.) senza che peraltro i pazienti mostrino alcuna forma effettiva di partecipazione o impegno personale nel mondo sociale.

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Tabella di Gravità

Assente Minimo Lieve Moderato Moderatamente grave Grave Molto grave Frequenza Non Dubbio Sporadico non Poco ricorrente Molto ricorrente Pervasivo Continuo applicabile ricorrente (≤ 1/sett) (≥1/sett) (quasi tutti i (tutti i giorni) giorni) Intensità Distress/arousal Distress/arousal Distress/arousal Distress/arousal grave Distress/arousal Distress/arousal soggettiva minimo e lieve moderato molto grave estremo di arousal o tollerabile distress Impairment Il Raro bisogno di Occasionale Frequente Occasionale Frequente Completo funzionamento evitare attività evitamento di evitamento di evitamento di attività evitamento evitamento del paziente sociali attività sociali non attività sociali non sociali essenziali della maggior delle attività non è essenziali essenziali parte delle sociali compromesso attività sociali essenziali Coping Il paziente Il paziente è Il paziente sceglie Il paziente Il paziente riconosce il Il paziente Il paziente è in grado in grado di attivamente di pensa di avere problema, ma non può ha solo una pensa di non di risolvere ristrutturare il evitare questi problemi che può farci nulla versione non avere alcun rapidamente proprio modo disagi (strategia spesso evitare plausibile del problema questi disagi di pensare comportamentale) passivamente problema che (ignorare) deve affrontare

308